In the study of psychology, neuroticism has been considered a fundamental personality trait.
For example, in the Big Five approach to personality trait theory, individuals with high scores for neuroticism are more likely than average to be moody and to experience such feelings as anxiety, worry, fear, anger, frustration, envy, jealousy, guilt, depressed mood, and loneliness. Such people are thought to respond worse to stressors and are more likely to interpret ordinary situations, such as minor frustrations, as appearing hopelessly difficult. They are described as often being self-conscious and shy, and tending to have trouble controlling urges and delaying gratification.
People with high scores on the neuroticism index are thought to be at risk of developing common mental disorders (mood disorders, anxiety disorders, and substance use disorders have been studied), and the sorts of symptoms traditionally referred to as “neuroses”.
Neuroticism is a trait in many models within personality theory, but there is significant disagreement on its definition. It is sometimes defined as a tendency for quick arousal when stimulated and slow relaxation from arousal, especially with regard to negative emotional arousal. Another definition focuses on emotional instability and negativity or maladjustment, in contrast to emotional stability and positivity, or good adjustment. It has also been defined in terms of lack of self-control, poor ability to manage psychological stress, and a tendency to complain.
Various personality tests produce numerical scores, and these scores are mapped onto the concept of “neuroticism” in various ways, which has created some confusion in the scientific literature, especially with regard to sub-traits or “facets”.
Individuals who score low in neuroticism tend to be more emotionally stable and less reactive to stress. They tend to be calm, even-tempered, and less likely to feel tense or rattled. Although they are low in negative emotion, they are not necessarily high in positive emotion. Being high in scores of positive emotion is generally an element of the independent trait of extraversion. Neurotic extraverts, for example, would experience high levels of both positive and negative emotional states, a kind of “emotional roller coaster”.
Like other personality traits, neuroticism is typically viewed as a continuous dimension rather than a discrete state.
The extent of neuroticism is generally assessed using self-report measures, although peer-reports and third-party observation can also be used. Self-report measures are either lexical or based on statements. Deciding which measure of either type to use in research is determined by an assessment of psychometric properties and the time and space constraints of the study being undertaken.
Lexical measures use individual adjectives that reflect neurotic traits, such as anxiety, envy, jealousy, and moodiness, and are very space and time efficient for research purposes. Lewis Goldberg (1992) developed a 20-word measure as part of his 100-word Big Five markers. Saucier (1994) developed a briefer 8-word measure as part of his 40-word mini-markers. Thompson (2008) systematically revised these measures to develop the International English Mini-Markers which has superior validity and reliability in populations both within and outside North America. Internal consistency reliability of the International English Mini-Markers for the Neuroticism (emotional stability) measure for native English-speakers is reported as 0.84, and that for non-native English-speakers is 0.77.
Statement measures tend to comprise more words, and hence consume more research instrument space, than lexical measures. Respondents are asked the extent to which they, for example, “Remain calm under pressure”, or “Have frequent mood swings”. While some statement-based measures of neuroticism have similarly acceptable psychometric properties in North American populations to lexical measures, their generally emic development makes them less suited to use in other populations. For instance, statements in colloquial North American English like “Seldom feel blue” and “Am often down in the dumps” are sometimes hard for non-native English-speakers to understand.
Neuroticism has also been studied from the perspective of Gray’s biopsychological theory of personality, using a scale that measures personality along two dimensions: the behavioural inhibition system (BIS) and the behavioural activation system (BAS). The BIS is thought to be related to sensitivity to punishment as well as avoidance motivation, while the BAS is thought to be related to sensitivity to reward as well as approach motivation. Neuroticism has been found to be positively correlated with the BIS scale, and negatively correlated with the BAS scale.
Neuroticism has been included as one of the four dimensions that comprise core self-evaluations, one’s fundamental appraisal of oneself, along with locus of control, self-efficacy, and self-esteem. The concept of core self-evaluations was first examined by Judge, Locke, and Durham (1997), and since then evidence has been found to suggest these have the ability to predict several work outcomes, specifically, job satisfaction and job performance.
There is a risk of selection bias in surveys of neuroticism; a 2012 review of N-scores said that “many studies used samples drawn from privileged and educated populations”.
Neuroticism is highly correlated with the startle reflex in response to fearful conditions and inversely correlated with it in response to disgusting or repulsive stimuli. This suggests that Neuroticism may increase vigilance where evasive action is possible but promote emotional blunting when escape is not an option. A measure of the startle reflex can be used to predict the trait neuroticism with good accuracy; a fact that is thought by some to underlie the neurological basis of the trait. The startle reflex is a reflex in response to a loud noise that one typically has no control over, though anticipation can reduce the effect. The strength of the reflex as well as the time until the reflex ceases can be used to predict neuroticism.
Mental Disorder Correlations
Questions used in many neuroticism scales overlap with instruments used to assess mental disorders like anxiety disorders (especially social anxiety disorder) and mood disorders (especially major depressive disorder), which can sometimes confound efforts to interpret N scores and makes it difficult to determine whether each of neuroticism and the overlapping mental disorders might cause the other, or if both might stem from other cause. Correlations can be identified.
A 2013 meta-analysis found that a wide range of clinical mental disorders are associated with elevated levels of neuroticism compared to levels in the general population. It found that high neuroticism is predictive for the development of anxiety disorders, major depressive disorder, psychosis, and schizophrenia, and is predictive but less so for substance use and non-specific mental distress. These associations are smaller after adjustment for elevated baseline symptoms of the mental illnesses and psychiatric history.
Neuroticism has also been found to be associated with older age. In 2007, Mroczek & Spiro found that among older men, upward trends in neuroticism over life as well as increased neuroticism overall both contributed to higher mortality rates.
Disorders associated with elevated neuroticism include mood disorders, such as depression and bipolar disorder, anxiety disorders, eating disorders, schizophrenia and schizoaffective disorder, dissociative identity disorder, and hypochondriasis. Mood disorders tend to have a much larger association with neuroticism than most other disorders. The five big studies have described children and adolescents with high neuroticism as “anxious, vulnerable, tense, easily frightened, ‘falling apart’ under stress, guilt-prone, moody, low in frustration tolerance, and insecure in relationships with others,” which includes both traits concerning the prevalence of negative emotions as well as the response to these negative emotions. Neuroticism in adults similarly was found to be associated with the frequency of self-reported problems.
These associations can vary with culture: for example, Adams found that among upper-middle-class American teenaged girls, neuroticism was associated with eating disorders and self-harm, but among Ghanaian teenaged girls, higher neuroticism was associated with magical thinking and extreme fear of enemies.
A 2004 meta-analysis attempted to analyse personality disorders in light of the five-factor personality theory and failed to find meaningful discriminations; it did find that elevated neuroticism is correlated with many personality disorders.
Theories of Causation
Studies have found that the mean reaction times will not differ between individuals high in neuroticism and those low in neuroticism, but that, with individuals high in neuroticism, there is considerably more trial-to-trial variability in performance reflected in reaction time standard deviations. In other words, on some trials neurotic individuals are faster than average, and on others they are slower than average. It has been suggested that this variability reflects noise in the individual’s information processing systems or instability of basic cognitive operations (such as regulation processes), and further that this noise originates from two sources: mental preoccupations and reactivity processes.
Flehmig et al. (2007) studied mental noise in terms of everyday behaviours using the Cognitive Failures Questionnaire, which is a self-report measure of the frequency of slips and lapses of attention. A “slip” is an error by commission, and a “lapse” is an error by omission. This scale was correlated with two well-known measures of neuroticism, the BIS/BAS scale and the Eysenck Personality Questionnaire. Results indicated that the CFQ-UA (Cognitive Failures Questionnaire- Unintended Activation) subscale was most strongly correlated with neuroticism (r = .40) and explained the most variance (16%) compared to overall CFQ scores, which only explained 7%. The authors interpret these findings as suggesting that mental noise is “highly specific in nature” as it is related most strongly to attention slips triggered endogenously by associative memory. In other words, this may suggest that mental noise is mostly task-irrelevant cognitions such as worries and preoccupations.
The theory of evolution may also explain differences in personality. For example, one of the evolutionary approaches to depression focuses on neuroticism and finds that heightened reactivity to negative outcomes may have had a survival benefit, and that furthermore a positive relationship has been found between neuroticism level and success in university with the precondition that the negative effects of neuroticism are also successfully coped with. Likewise, a heightened reactivity to positive events may have had reproductive advantages, selecting for heightened reactivity generally. Nettle contends that evolution selected for higher levels of neuroticism until the negative effects of neuroticism outweighed its benefits, resulting in selection for a certain optimal level of neuroticism. This type of selection will result in a normal distribution of neuroticism, so the extremities of the distribution will be individuals with excessive neuroticism or too low neuroticism for what is optimal, and the ones with excessive neuroticism would therefore be more vulnerable to the negative effects of depression, and Nettle gives this as the explanation for the existence of depression rather than hypothesizing, as others have, that depression itself has any evolutionary benefit.
Some research has found that neuroticism, in modern societies, is positively correlated with reproductive success in females but not in males. A possible explanation may be that neuroticism in females comes at the expense of formal education (which is correlated with lower fertility) and correlates with unplanned and adolescent pregnancies.
Terror Management Theory
According to terror management theory (TMT) neuroticism is primarily caused by insufficient anxiety buffers against unconscious death anxiety. These buffers consist of:
Cultural worldviews that impart life with a sense of enduring meaning, such as social continuity beyond one’s death, future legacy and afterlife beliefs, and
A sense of personal value, or the self-esteem in the cultural worldview context, an enduring sense of meaning.
While TMT agrees with standard evolutionary psychology accounts that the roots of neuroticism in Homo sapiens or its ancestors are likely in adaptive sensitivities to negative outcomes, it posits that once Homo sapiens achieved a higher level of self-awareness, neuroticism increased enormously, becoming largely a spandrel, a non-adaptive by-product of our adaptive intelligence, which resulted in a crippling awareness of death that threatened to undermine other adaptive functions. This overblown anxiety thus needed to be buffered via intelligently creative, but largely fictitious and arbitrary notions of cultural meaning and personal value. Since highly religious or supernatural conceptions of the world provide “cosmic” personal significance and literal immortality, they are deemed to offer the most efficient buffers against death anxiety and neuroticism. Thus, historically, the shift to more materialistic and secular cultures – starting in the Neolithic, and culminating in the industrial revolution, is deemed to have increased neuroticism.
Genetic and Environmental Factors
A 2013 review found that “Neuroticism is the product of the interplay between genetic and environmental influences. Heritability estimates typically range from 40% to 60%.” The effect size of these genetic differences remain largely the same throughout development, but the hunt for any specific genes that control neuroticism levels has “turned out to be difficult and hardly successful so far.” On the other hand, with regards to environmental influences, adversities during development such as “emotional neglect and sexual abuse” were found to be positively associated with neuroticism. However, “sustained change in neuroticism and mental health are rather rare or have only small effects.”
In the July 1951 article: “The Inheritance of Neuroticism” by Hans J. Eysenck and Donald Prell it was reported that some 80 per cent of individual differences in neuroticism are due to heredity and only 20 percent are due to environment….the factor of neuroticism is not a statistical artifact, but constitutes a biological unit which is inherited as a whole….neurotic predisposition is to a large extent hereditarily determined.
In children and adolescents, psychologists speak of temperamental negative affectivity that, during adolescence, develops into the neuroticism personality domain. Mean neuroticism levels change throughout the lifespan as a function of personality maturation and social roles, but also the expression of new genes. Neuroticism in particular was found to decrease as a result of maturity by decreasing through age 40 and then levelling off. Generally speaking, the influence of environments on neuroticism increases over the lifespan, although people probably select and evoke experiences based on their neuroticism levels.
The emergent field of “imaging genetics,” which investigates the role of genetic variation in the structure and function of the brain, has studied certain genes suggested to be related to neuroticism, and the one studied so far concerning this topic has been the serotonin transporter-linked promoter region gene known as 5-HTTLPR, which is transcribed into a serotonin transporter that removes serotonin. It has been found that compared to the long (l) variant of 5-HTTLPR, the short (s) variant has reduced promoter activity, and the first study on this subject has shown that the presence of the s-variant 5-HTTLPR has been found to result in higher amygdala activity from seeing angry or fearful faces while doing a non-emotional task, with further studies confirming that the s-variant 5-HTTLPR result greater amygdala activity in response to negative stimuli, but there have also been null findings. A meta-analysis of 14 studies has shown that this gene has a moderate effect size and accounts for 10% of the phenotypic difference. However, the relationship between brain activity and genetics may not be completely straightforward due to other factors, with suggestions made that cognitive control and stress may moderate the effect of the gene. There are two models that have been proposed to explain the type of association between the 5-HTTLPR gene and amygdala activity: the “phasic activation” model proposes that the gene controls amygdala activity levels in response to stress, whereas the “tonic activation” model, on the other hand, proposes that the gene controls baseline amygdala activity. Another gene that has been suggested for further study to be related to neuroticism is the catechol-O-methyltransferase (COMT) gene.
The anxiety and maladaptive stress responses that are aspects of neuroticism have been the subject of intensive study. Dysregulation of hypothalamic-pituitary-adrenal axis and glucocorticoid system, and influence of different versions of the serotonin transporter and 5-HT1A receptor genes may influence the development of neuroticism in combination with environmental effects like the quality of upbringing.
Neuroimaging studies with fMRI have had mixed results, with some finding that increased activity in the amygdala and anterior cingulate cortex, brain regions associated with arousal, is correlated with high neuroticism scores, as is activation of the associations have also been found with the medial prefrontal cortex, insular cortex, and hippocampus, while other studies have found no correlations. Further studies have been conducted trying to tighten experimental design by using genetics to add additional differentiation among participants, as well as twin study models.
A related trait, behavioural inhibition, or “inhibition to the unfamiliar,” has received attention as the trait concerning withdrawal or fear from unfamiliar situations, which is generally measured through observation of child behaviour in response to, for example, encountering unfamiliar individuals. This trait in particular has been hypothesized to be related to amygdala function, but the evidence so far has been mixed.
Age, Gender, and Geographic Patterns
A 2013 review found that groups associated with higher levels of neuroticism are young adults who are at high risk for mood disorders. Research in large samples has shown that levels of neuroticism are higher in women than men. Neuroticism is found to decrease slightly with age. The same study noted that no functional MRI studies have yet been performed to investigate these differences, calling for more research. A 2010 review found personality differences between genders to be between “small and moderate,” the largest of those differences being in the traits of agreeableness and neuroticism. Many personality traits were found to have had larger personality differences between men and women in developed countries compared to less developed countries, and differences in three traits – extraversion, neuroticism, and people-versus-thing orientation – showed differences that remained consistent across different levels of economic development, which is also consistent with the “possible influence of biologic factors.” Three cross-cultural studies have revealed higher levels of female neuroticism across almost all nations.
Geographically, a 2016 review said that in the US, neuroticism is highest in the mid-Atlantic states and southwards and declines westward, while openness to experience is highest in ethnically diverse regions of the mid-Atlantic, New England, the West Coast, and cities. Likewise, in the UK neuroticism is lowest in urban areas. Generally, geographical studies find correlations between low neuroticism and entrepreneurship and economic vitality and correlations between high neuroticism and poor health outcomes. The review found that the causal relationship between regional cultural and economic conditions and psychological health is unclear.
Personality disorders (PD) are a class of mental disorders characterised by enduring maladaptive patterns of behaviour, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual’s culture.
Personality, defined psychologically, is the set of enduring behavioural and mental traits that distinguish individual humans. Hence, PDs are defined by experiences and behaviours that deviate from social norms and expectations. Those diagnosed with a PD may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. In general, PDs are diagnosed in 40-60% of psychiatric patients, making them the most frequent of psychiatric diagnoses.
PDs are characterised by an enduring collection of behavioural patterns often associated with considerable personal, social, and occupational disruption. PDs are also inflexible and pervasive across many situations, largely due to the fact that such behaviour may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are therefore perceived to be appropriate by that individual. In addition, people with personality disorders often lack insight into their condition and so refrain from seeking treatment. This behaviour can result in maladaptive coping skills and may lead to personal problems that induce extreme anxiety, distress, or depression and result in impaired psychosocial functioning. These behaviour patterns are typically recognised by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life.
While emerging treatments, such as dialectical behaviour therapy, have demonstrated efficacy in treating PDs, such as borderline personality disorder, PDs are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorise PDs, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of PDs are based strictly on social, or even sociopolitical and economic considerations.
Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks. For example, the Greek philosopher Theophrastus described 29 ‘character’ types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen’s concept of personality types, which he linked to the four humours proposed by Hippocrates.
Such views lasted into the eighteenth century, when experiments began to question the supposed biologically based humours and ‘temperaments’. Psychological concepts of character and ‘self’ became widespread. In the nineteenth century, ‘personality’ referred to a person’s conscious awareness of their behaviour, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term ‘multiple personality disorder’ in the first versions of the DSM.
Physicians in the early nineteenth century started to diagnose forms of insanity involving disturbed emotions and behaviours but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as ‘ manie sans délire ‘ – mania without delusions – and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. ‘Moral’ in this sense referred to affect (emotion or mood) rather than ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so social control should take precedence. These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about ‘psychopaths’. Separately, Richard von Krafft-Ebing popularised the terms sadism and masochism, as well as homosexuality, as psychiatric issues.
The German psychiatrist Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase ‘psychopathic inferiority’, theorised to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgement. Described as deeply rooted in his Christian faith, his work established the concept of personality disorder as used today.
In the early 20th century, another German psychiatrist, Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types:
The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid vagabonds who wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid, schizotypal; interpretations of earlier (1921) theories of Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder.
In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin published his book Manifestations of Psychopathies: Statics, Dynamics, Systematic Aspects, which was one of the first attempts to develop a detailed typology of psychopathies. Regarding maladaptation, ubiquity, and stability as the three main symptoms of behavioural pathology, he distinguished nine clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), asthenics (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid. Some elements of Gannushkin’s typology were later incorporated into the theory developed by a Russian adolescent psychiatrist, Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called accentuations of character.
In 1939, psychiatrist David Henderson published a theory of ‘psychopathic states’ that contributed to popularly linking the term to anti-social behaviour. Hervey M. Cleckley’s 1941 text, The Mask of Sanity, based on his personal categorisation of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage.
Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by Sigmund Freud and others. This included the concept of character disorders, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were often understood as weaknesses of character or wilful deviance, and were distinguished from neurosis or psychosis. The term ‘borderline’ stems from a belief some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive-compulsive and histrionic, the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel William Menninger during World War II in the context of men’s reactions to military compliance, which would later be referenced as a personality disorder in the DSM. Otto Kernberg was influential with regard to the concepts of borderline and narcissistic personalities later incorporated in 1980 as disorders into the DSM.
Meanwhile, a more general personality psychology had been developing in academia and to some extent clinically. Gordon Allport published theories of personality traits from the 1920s – and Henry Murray advanced a theory called personology, which influenced a later key advocate of personality disorders, Theodore Millon. Tests were developing or being applied for personality evaluation, including projective tests such as the Rorshach, as well as questionnaires such as the Minnesota Multiphasic Personality Inventory. Around mid-century, Hans Eysenck was analysing traits and personality types, and psychiatrist Kurt Schneider was popularising a clinical use in place of the previously more usual terms ‘character’, ‘temperament’ or ‘constitution’.
American psychiatrists officially recognised concepts of enduring personality disturbances in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate ‘axis’ along with mental retardation, intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. ‘Inadequate’ and ‘asthenic’ personality disorder’ categories were deleted, and others were expanded into more types, or changed from being personality disorders to regular disorders. Sociopathic personality disorder, which had been the term for psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific ‘operationalised’ definitions, with standard criteria psychiatrists could agree on to conduct research and diagnose patients. In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed ‘depressive personality disorder’ was added; in addition, the official diagnosis of passive-aggressive personality disorder was dropped, tentatively renamed ‘negativistic personality disorder.’
International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider argued they were ‘abnormal varieties of psychic life’ and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviours associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.
The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians.
The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5-1% for the least common, such as narcissistic and avoidant.
A screening survey across 13 countries by the WHO using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders. In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).
A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely in need of services was a much smaller group.
Personality disorders (especially Cluster A) are also very common among homeless people.
There are some sex differences in the frequency of personality disorders which are shown below (type of PD/predominant gender):
Paranoid personality disorder: Male.
Schizoid personality disorder: Male.
Schizotypal personality disorder: Male.
Antisocial personality disorder: Male.
Borderline personality disorder: Female.
Histrionic personality disorder: Female.
Narcissistic personality disorder: Male.
Avoidant personality disorder: Male.
Dependent personality disorder: Female.
Depressive personality disorder: Female.
Passive–aggressive personality disorder: Male.
Obsessive-compulsive personality disorder: Male.
Self-defeating personality disorder: Female.
Sadistic personality disorder: Male.
The two relevant major systems of classification are:
The ICD system is a collection of numerical codes that have been assigned to all known clinical disease states, which provides uniform terminology for medical records, billing, and research purposes. The DSM defines psychiatric diagnoses based on research and expert consensus, and its content informs the ICD-10 classifications. Both have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.
Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.
The ICD-10 lists these general guideline criteria:
Markedly disharmonious attitudes and behaviour, generally involving several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
The abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
The abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
The above manifestations always appear during childhood or adolescence and continue into adulthood;
The disorder leads to considerable personal distress but this may only become apparent late in its course;
The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
The ICD adds: “For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.”
In DSM-5, any personality disorder diagnosis must meet the following criteria:
An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e. ways of perceiving and interpreting self, other people, and events).
Affectivity (i.e. the range, intensity, lability, and appropriateness of emotional response).
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
The enduring pattern is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. head trauma).
Chapter V in the ICD-10 contains the mental and behavioural disorders and includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.
The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.
Besides the ten specific PD, there are the following categories:
Other specific personality disorders (involves PD characterised as eccentric, haltlose, immature, narcissistic, passive-aggressive, or psychoneurotic).
Personality disorder, unspecified (includes “character neurosis” and “pathological personality”).
Mixed and other personality disorders (defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
Enduring personality changes, not attributable to brain damage and disease (this is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).
In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis “personality disorder”. Instead, there will be specifiers called “prominent personality traits” and the possibility to classify degrees of severity ranging from “mild”, “moderate”, and “severe” based on the dysfunction in interpersonal relationships and everyday life of the patient.
There are six prominent personality traits/patterns categorised by the ICD-11:
Detachment (“tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment).”).
Dissociality (“disregard for the rights and feelings of others, encompassing both self-centredness and lack of empathy.” Equivalent to the DSM-5 classification of antisocial personality disorder.).
Disinhibition (“tendency to act rashly based on immediate external or internal stimuli (i.e., sensations, emotions, thoughts), without consideration of potential negative consequences.”).
Anankastia (“narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards.” Equivalent to the DSM-5 classification of obsessive-compulsive personality disorder.),
Borderline pattern (“pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity”. Equivalent to the DSM-5 classification of borderline personality disorder.),
The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate ‘axis’, as previously.
DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.
The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:
Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.
The specific personality disorders are grouped into the following three clusters based on descriptive similarities:
Cluster A (Odd or Eccentric Disorders)
Cluster A personality disorders are often associated with schizophrenia: in particular, schizotypal personality disorder shares some of its hallmark symptoms with schizophrenia, e.g., acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour. However, people diagnosed with odd-eccentric personality disorders tend to have a greater grasp on reality than those with schizophrenia. Patients suffering from these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Though their perceptions may be unusual, these anomalies are distinguished from delusions or hallucinations as people suffering from these would be diagnosed with other conditions. Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.
Paranoid personality disorder: characterised by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent.
Cluster B (Dramatic, Emotional or Erratic Disorders)
Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour.
Borderline personality disorder: pervasive pattern of abrupt emotional outbursts, altered empathy, instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivity.
Narcissistic personality disorder: pervasive pattern of superior grandiosity, need for admiration, and a perceived or real lack of empathy. In a more severe expression, narcissistic personality disorder may show evidence of paranoia, aggression, psychopathy, and sadistic personality disorder, which is known as malignant narcissism.
Obsessive-compulsive personality disorder: characterised by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct from obsessive-compulsive disorder).
Other Personality Types
Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behaviour) and self-defeating personality disorder or masochistic personality disorder (characterised by behaviour consequently undermining the person’s pleasure and goals). They were listed in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria. The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.
Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:
Type of Personality Disorder
Guarded, defensive, distrustful and suspicious. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feel righteous, but persecuted. Experience a pattern of pervasive distrust and suspicion of others that lasts a long time. They are generally difficult to work with and are very hard to form relationships with. They are also known to be somewhat short-tempered.
Apathetic, indifferent, remote, solitary, distant, humourless, contempt, odd fantasies. Neither desire nor need human attachments. Withdrawn from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of the feelings of themselves or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, they may appear somewhat dull or humourless. Because they don’t tend to show emotion, they may appear as though they don’t care about what’s going on around them.
Eccentric, self-estranged, bizarre, absent. Exhibit peculiar mannerisms and behaviours. Think they can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blur line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They think others think negatively of them.
Impulsive, irresponsible, deviant, unruly. Act without due consideration. Meet social obligations only when self-serving. Disrespect societal customs, rules, and standards. See themselves as free and independent. People with antisocial personality disorder depict a long pattern of disregard for other people’s rights. They often cross the line and violate these rights.
Unpredictable, egocentric, emotionally unstable. Frantically fears abandonment and isolation. Experience rapidly fluctuating moods. Shift rapidly between loving and hating. See themselves and others alternatively as all-good and all-bad. Unstable and frequently changing moods. People with borderline personality disorder have a pervasive pattern of instability in interpersonal relationships.
Hysteria, dramatic, seductive, shallow, egocentric, attention-seeking, vain. Overreact to minor events. Exhibitionistic as a means of securing attention and favours. See themselves as attractive and charming. Constantly seeking others’ attention. Disorder is characterised by constant attention-seeking, emotional overreaction, and suggestibility. Their tendency to over-dramatise may impair relationships and lead to depression, but they are often high-functioning.
Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. See themselves as admirable and superior, and therefore entitled to special treatment. Is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they are superior to others and have little regard for other people’s feelings.
Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. See themselves as inept, inferior, or unappealing. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.
Helpless, incompetent, submissive, immature. Withdrawn from adult responsibilities. See themselves as weak or fragile. Seek constant reassurance from stronger figures. They have the need to be taken care of by a person. They fear being abandoned or separated from important people in their life.
Restrained, conscientious, respectful, rigid. Maintain a rule-bound lifestyle. Adhere closely to social conventions. See the world in terms of regulations and hierarchies. See themselves as devoted, reliable, efficient, and productive.
Sombre, discouraged, pessimistic, brooding, fatalistic. Present themselves as vulnerable and abandoned. Feel valueless, guilty, and impotent. Judge themselves as worthy only of criticism and contempt. Hopeless, suicidal, restless. This disorder can lead to aggressive acts and hallucinations.
Resentful, contrary, sceptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vent anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn. Withhold emotions. Will not communicate when there is something problematic to discuss.
Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Gain satisfaction through dominating, intimidating and humiliating others. They are opinionated and closed-minded. Enjoy performing brutal acts on others. Find pleasure in abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.
Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourage others to take advantage of them. Deliberately defeat own achievements. Seek condemning or mistreatful partners. They are suspicious of people who treat them well. Would likely engage in a sadomasochist relationship.
In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.
This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.
Dimensional System of Classifying Personality Disorders
Level of Severity
Definition by Categorical System
No personality disorder
Does not meet actual or subthreshold criteria for any personality disorder.
Meets sub-threshold criteria for one or several personality disorders.
Simple personality disorder
Meets actual criteria for one or more personality disorders within the same cluster.
Complex (diffuse) personality disorder
Meets actual criteria for one or more personality disorders within more than one cluster.
Severe personality disorder
Meets criteria for creation of severe disruption to both individual and to many in society.
There are several advantages to classifying personality disorder by severity:
It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.
It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality disorder versus personality disorder.
This system accommodates the new diagnosis of severe personality disorder, particularly “dangerous and severe personality disorder” (DSPD).
Effect on Social Functioning
Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables. The Personality Assessment Schedule gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.
Many who have a personality disorder do not recognise any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamour for treatment. The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.
There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another. Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits.
Impact on Functioning
It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.
In several studies, higher disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorder. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive-compulsive PD was not related to a compromised QoL or dysfunction. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.
One study investigated some aspects of “life success” (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive-compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.
There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.
In the Workplace
Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace – potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.
In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:
Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.
According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.
Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood. In addition, in Robert F. Krueger’s review of their research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.
Versus Mental Disorders
The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioural maintenance or inhibition, respectively. But they may also have a spectrum relationship to certain syndromal mental disorders:
Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse-control disorders, eating disorders, ADHD, or a substance use disorder.
Avoidant personality disorder is seen with social anxiety disorder.
Versus Normal Personality
The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM-5 and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality.
Thomas Widiger and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed the Five Factor Model of personality as an alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e. high neuroticism), impulsivity (i.e. low conscientiousness), and hostility (i.e. low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model. This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within DSM-5.
In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time-consuming.
As of 2002, there were over fifty published studies relating the five factor model (FFM) to personality disorders. Since that time, quite a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains. In her seminal review of the personality disorder literature published in 2007, Lee Anna Clark asserted that “the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits”.
The five factor model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.
Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled “The five-factor model and personality disorder empirical literature: A meta-analytic review”, the authors analysed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.
Openness to Experience
At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight (means the ability to recognise one’s own mental illness here) and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.
High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioural patterns.
The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests. Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one’s emotional experiences. It is most characteristic of obsessive-compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders.
Currently, there are no definitive proven causes for personality disorders. However, there are numerous possible causes and known risk factors supported by scientific research that vary depending on the disorder, the individual, and the circumstance. Overall, findings show that genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders.
Child abuse and neglect consistently show up as risk factors to the development of personality disorders in adulthood. A study looked at retrospective reports of abuse of participants that had demonstrated psychopathology throughout their life and were later found to have past experience with abuse. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not experience such verbal abuse) to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behaviour. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.
Socioeconomic status has also been looked at as a potential cause for personality disorders. There is a strong association with low parental/neighbourhood socioeconomic status and personality disorder symptoms. In a 2015 publication from Bonn, Germany, which compared parental socioeconomic status and a child’s personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher IQs. These traits correlate with a low risk of developing personality disorders later on in life. In a study looking at female children who were detained for disciplinary actions found that psychological problems were most negatively associated with socioeconomic problems. Furthermore, social disorganisation was found to be inversely correlated with personality disorder symptoms.
Evidence shows personality disorders may begin with parental personality issues. These cause the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships. By either genetic or modelling mechanisms, children can pick up these traits. Additionally, poor parenting appears to have symptom elevating effects on personality disorders. More specifically, lack of maternal bonding has also been correlated with personality disorders. In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls). These researchers suggested this act may be essential in fostering maternal relationships. Additionally, findings suggest personality disorders show a negative correlation with two attachment variables: maternal availability and dependability. When left unfostered, other attachment and interpersonal problems occur later in life ultimately leading to development of personality disorders.
Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms.
Research shows a malfunctioning inner brain: hippocampus up to 18% smaller, a smaller amygdala, malfunctions in the striatum-nucleus accumbens and the cingulum neural pathways connecting them and taking care of the feedback loops on what to do with all the incoming information from the multiple senses; so what comes out is anti-social – not according to what is the social norm, socially acceptable and appropriate.
There are many different forms (modalities) of treatment used for personality disorders:
Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term (brief) forms.
Family therapy, including couples therapy.
Group therapy for personality dysfunction is probably the second most used.
Psychological-education may be used as an addition.
Self-help groups may provide resources for personality disorders.
Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions.
Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities.
The practice of mindfulness that includes developing the ability to be non-judgementally aware of unpleasant emotions appears to be a promising clinical tool for managing different types of personality disorders.
There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioural techniques. In clinical practice, many therapists use an ‘eclectic’ approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries).
Response of Patients with Personality Disorders to Biological and Psychosocial Treatments
Evidence for Brain Dysfunction
Response to Biological Treatments
Response to Psychosocial Treatments
Evidence for relationship to schizophrenia; otherwise none known.
Schizotypal patients may improve on antipsychotic medication; otherwise not indicated.
Poor. Supportive psychotherapy may help.
Evidence for relationship to bipolar disorder; otherwise none known.
Antidepressants, antipsychotics, or mood stabilizers may help for borderline personality; otherwise not indicated.
Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities.
Evidence for relationship to generalized anxiety disorder; otherwise none known.
No direct response. Medications may help with comorbid anxiety and depression.
Most common treatment for these disorders. Response variable.
The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organisations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviours. The disruptiveness that people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage.
Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient’s ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between ‘normal’ and ‘abnormal’ personalities. There is substantial social stigma and discrimination related to the diagnosis.
The term ‘personality disorder’ encompasses a wide range of issues, each with a different level of severity or disability; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterised by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioural addictions. A person may meet the criteria for dissociative identity disorder (formerly “multiple personality disorder”) diagnoses and/or other mental disorders, either at particular times or continually, thus making coordinated input from multiple services a potential requirement.
Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be perceived as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defence mechanisms, or deliberate strategies; and in terms of moral judgments or the need to consider underlying motivations for specific behaviours or conflicts. The vulnerabilities of a client, and indeed a therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and views that both the client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. As an example of one extreme, people who may have been exposed to hostility, deceptiveness, rejection, aggression or abuse in their lives, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client’s issues.
Personality disorder not otherwise specified (PDNOS) is a diagnostic classification for some DSM-IV Axis II personality disorders not otherwise listed in DSM-IV.
The DSM-5 does not have an equivalent to Personality Disorder NOS. However Personality disorder-trait specified (PD-TS) remains under consideration for future revisions. The DSM 5 “Unspecified Disorder” is not a personality disorder, it is used to enhance specificity of an existing disorder or it is an emergency diagnosis unto itself (i.e. Unspecified Mental Disorder, 300.9), without being attached to another disorder.
Not to be confused with PDD-NOS (Pervasive Developmental Disorder Not Otherwise Specified).
This diagnosis may be given when no other personality disorder defined in the DSM fits the patient’s symptoms.
Four personality disorders were excluded from the main body of the DSM-IV-TR but this diagnosis may be used instead. The four excluded personality disorders are:
Haltlose personality disorder is a personality disorder in which affected individuals possess psychopathic traits built upon short-sighted selfishness and irresponsible hedonism, combined with an inability to anchor one’s identity to a future or past. The symptoms of Haltlose are characterised by a lack of inhibition.
Refer to Hysteroid Dysphoria. Other names have included Willenloser Psychopath, Unstable Psychopath, Unstable Drifter, and Disinhibited Personality.
Described by Emil Kraepelin and Gustav Aschaffenburg in the early twentieth century, and further distinguished by Karl Jaspers, Eugen and Manfred Bleuler, it has been colloquially dubbed psychopathy with an “absence of intent or lack of will”.
With other hyperthymics, Haltlose personalities were considered to make up “the main component of serious crime”, and are studied as one of the strains of psychopathy relevant to criminology as they are “very easily involved in the criminal history” and may become aggressors or homicidal. Their psychopathy is difficult to identify as a shallow sense of conformity is always present. A 2020 characterisation of mental illnesses noted of the Haltlose that “these people constantly need vigilant control, leadership, authoritarian mentor, encouragement and behavior correction” to avoid an idle lifestyle, involvement in antisocial groups, crime and substance abuse. The marked tendencies towards suggestibility are off-set by demonstrations of “abnormal rigidity and intransigence and firmness”.
After discovering a guilty conscience due to some act or omission they have committed, “they then live under constant fear of the consequences of their action or inaction, fear of something bad that might strike them” in stark opposition to their apparent carelessness or hyperthymic temperament, which is itself frequently a subconscious reaction to overwhelming fear. They frequently withdraw from society. Given their tendency to “exaggerate, to embroider their narratives, to picture themselves in ideal situations, to invent stories”, this fear then manifests as being “apt to blame others for their offences, frequently seeking to avoid responsibility for their actions”. They do not hold themselves responsible for their failed life, instead identifying as an ill-treated martyr.
They were characterised as Dégénérés supérieurs, demonstrating normal or heightened intellect but degraded moral standards. Of the ten types of psychopaths defined by Schneider, only the Gemütlose (compassionless) and the Haltlose “had high levels of criminal behavior” without external influence, and thus made up the minority of psychopaths who are “virtually doomed to commit crimes” by virtue only of their own constitution. Frequently changing their determined goals, a haltlose psychopath is “constantly looking for an external hold, it doesn’t really matter whether they join occult or fascist movements”. The ability to moderate external influence was considered one of three characteristics necessary to form an overall personality, thus leaving Haltlose patients without a functional personality of their own. A study of those with haltlose personality disorder concludes “In all of those cases, the result was a continuous social decline that ended in asocial-parasitic existence or an antisocial-criminal life”.
Haltlose has one of the most unfavourable prognoses of psychopathies. To exist safely, such a psychopath requires “a harsh lifestyle” and constant supervision.
Etymology and Criticism
“Haltlos” is a German word that contextually refers to a floundering, aimless, irresponsible lifestyle, and the diagnosis is named “Haltlose” using the feminine variation on the word. They are commonly clinically termed an “unstable psychopath”, which is differentiated from emotionally unstable personality disorder (an alternative name for borderline personality disorder). It was remarked in early studies that England, the United States and northern European countries did not use the same typology, not distinguishing between those psychopaths who were unstable and those who were “Unstable Psychopaths”.
It has been dubbed a part of “German-speaking psychiatry”. The term “Haltlose” is more common in the study of psychiatry, while “Willenlose” is preferred in sociology. Some like Karl Birnbaum prefer the term “Haltlose”, while others like Kurt Schneider prefer “Willenlos” shifting focus off their lack of self-control and opposed to the moralist tones of those like Birnbaum who had described the Haltlose as unable to grasp “important ideal values such as honor and morality, duty and responsibility, as well as material ones such as prosperity and health”. In 1928, Eugen Kahn argued Willenlose was a misnomer, as the patients demonstrated plenty of “will” and simply lacked the ability to translate it into action. Historically, researchers such as Schneider argued that instability is the symptom, whereas lack of volition is the underlying cause. It is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), possibly due to a modern belief that the concept of volition is outdated and overshadowed by the concepts of motivation and arousal or drive.
In 1963, Karl Jaspers defined the term as “those who have no willpower at all, the drifters, simply echoing any influence that impinges on them”. However, in 1976, the Government of Canada listed the alternate term “Unstable drifter” in a psychiatric criminology context as a problematic term for which they could not readily offer a French translation in accordance with their bilingualism laws. Similar issues have arisen trying to translate it to other languages, including Turkish. Ultimately the diagnosis was handicapped by the issues of translation, leading to criticism of “the impoverishment of psychiatric vocabulary” that led to declining research and use.
In the early 20th century, Aschaffenburg distanced himself from accusations that the diagnosis was intended to protect criminals from punishment, emphasizing instead that those with Haltlose personality disorder “generally cannot be exculpated”.
Dr. Friedrich Stumpfl cautioned against what he saw as a trend of diagnosing haltlose personality disorder without investigating comorbidities that may be even more pronounced. In condemning the idea of personality disorders generally, Joachim-Ernst Meyer suggested in 1976 that Schneider’s early description of the Haltlose personality disorder, as a lack of determination in aspects of life including parenting, could just as easily be described as an example of a neurosis rather than a psychopathy if studied only by its aetiology rather than its symptoms, and used it as an example of the nature versus nurture debate that surrounded all personality disorders. Critics ceded that the term “Haltlose” remained of value in educational and therapeutic contexts, while suggesting future collaboration between psychiatric research and sociologists would allow further definition.
Recently, it has been criticised as a “diagnosis of convenience [that] avoids all further deliberations about a psychopathic personality”. Dr. DM Svrakic and Dr. M Divac-Jovanovic suggested the ICD-10 explanations of Haltlose, Immature and Psychoneurotic personality disorders appeared “dubious”, and sociologist James Cosgrave found psychiatric use to represent a “fringe figure”. A graduate student at Bochumer Stadt & Studierendenzeitung condemned the historical diagnosis from an LGBT perspective, opining that “incredibly oppressive language” had been used by the psychiatrists studying it such as “pathological femininity”.
It may be that the evolution of test-batteries have minimised diagnoses of Haltlosen, differentiating it from some newer models in psychiatry.
Described as bearing a “pronounced heredity burden”, the propensity for Haltlose has also been suggested to be passed only through the maternal genes. Only able to offer “primitive reactions” and “poor and immature judgement”, they are noted to display an absolute lack of purpose in their lives “except for the simple biological need to continue living”.
Gustav von Bergmann, a specialist in internal medicine rather than psychiatry, wrote in 1936 that Haltlose personality disorder was entirely biological rather than fostered through psychological experiences. Indeed, Dr. Hans Luxenburger proposed in 1939 that a toxin in the metabolism, when present with Haltlose personality disorder, might be responsible for asthenic difficulties such as shortness of breath, nausea, and cluster headaches. Dr. E.H. Hughes noted that two-thirds of Huntington’s disease patients had previously been diagnosed as Haltlose or Gemütlose psychopaths.
A study in 1949 of different psychopathies under examination by electroencephalography recordings showed that borderline personalities and haltlose personalities had increased levels of dysrhythmia, whereas other subtypes of psychopathy did not show variation. An individual in 1931 was noted as having initially improved but relapsed “because of encephalitis”. As with other personality disorders, a 1923 article suggests it can also be acquired through encephalitis. In 2006, an Essex warehouse employee who suffered head injuries was awarded £3 million compensation on the basis it had caused him to develop Haltlose personality disorder, seeking out prostitutes and pornography which destroyed his marriage.
Mistakes cannot be fully avoided when placing children under care. even an experienced specialist often cannot distinguish between a blossoming hebephrenia and a Gemutlose or Haltlose personality disorder. Even with weeks of institutional observation, the certainty of our diagnostic aids can remain doubtful…under certain circumstances a doctor will advise medical care even at the risk of learning the patient cannot improve as a result of mental illness and will end up in a madhouse. Kurt Schneider.
Dr. W. Blankenburg posited in 1968 that those with haltlose personality disorder exhibited less categorical orientation than those patients who were simply unstable. By 1962, lobotomy was being tested as a possible means to limit the chaotic thinking of the Haltlose personality.
Kraepelin, in noting “an increased risk of criminal behavior”, estimated that 64% of men and 20% of women with Haltlose descended into alcoholism in the early twentieth century. The frequent intersection between HLPD and alcoholism means modern clinical researchers may use “haltlose” as a grouping when separating subjects by disposition. Research in 1915 noted an increased propensity for lavish spending, and overconsumption of coffee, tea and medication.
One 1954 study suggested female Haltlose patients may experience “manic excitement” during their menses. According to 1949 research, they have a higher rate of homosexuality, and 1939 evidence suggested that masturbation is more prevalent in Haltlose and Gemütlose (compassionless) psychopaths than in other disorders, and Haltlose erethics leave them “usually very sexually excited” and seeking out “atypical, irregular and unusual” debauchery whether in brothels, adultery or destroying marriages.
They demonstrate similarities to hysteroid dysphoria. In 1928, it was proposed that Fantasy prone personality was likely a subset of Haltlose personalities, suffering from maladaptive daydreaming and Absorption.
According to 1968 research, haltlose personality disorder is frequently comorbid with other mental health diagnoses, and rarely appears isolated on its own. Hans Heinze focused on his belief that Haltlose ultimately stemmed from a sense of inferiority, while Kramer held there was a battling inferiority complex and superiority complex.
The Haltlose were said to have a dynamic instinctual drive to “cling” to others, to avoid a horrible loneliness they fear – but they will always represent a “lurking danger” because they were unable to actually maintain the necessary relationship and were in a class with the “forever abandoned”. According to 1926 research, they view all interaction as a means of winning “indulgence from some people, help from other people”.
One early study indicated that 7.5% of psychopaths were Haltlose, and Kraepelin estimated that his own practice determined fewer than 20% of psychopaths he saw were Haltlose. However more recent studies, after differentiating out newer diagnoses, have suggested that it may be fewer than 1% of psychopaths who are truly Haltlose.
Described in 1922 as both “moody” and “passive”, they quickly switch from over-confidence in victory to sullen defiance.
Their emotional lability means they alternate between projecting an optimistic and competent image claiming they are “destined to do great things”, and a more honest cynicism and depression. Research in 1925 indicates they display “great emotional irritability, which may result in violent loss of temper…and interpret every limitation as an undeserved insult” and have a “pronounced lust for argument”. The symptoms are considered to worsen if patients are granted greater independence “in the home and in their work”.
Their self schema only encompasses the immediate present. They are described as “living in a random location and moment”. A common pitfall in therapy is that they proved in 1917 to be “very superficial, they easily acquire knowledge but do not apply it in any way and soon forget it”.
The essence of these people…playthings of external influences, allowing themselves to be carried away by events like a leaf in the wind! …Impermanence is everything. In one hour, they are happy and excited with the whole world lying open for them in the splendor of the joy of life, but the next hour casts aside this optimism and the future now seems bleak, gray on gray…sympathies and antipathies quickly replace each other, what was worshipped yesterday is burned today, and despite all oaths of eternal loyalty, the best friend is transformed into the deeply-loathed enemy overnight.” Dr. L. Scholz, Anomale Kinder, Berlin, 1919.
Those with HLPD display “a number of endearing qualities, charming with an apparent emotional warmth, but also an enhanced suggestibility and a superficiality of affect”, which can lead to unrealistic optimism. and “wandering through life without ever taking firm root”. They are also noted as “absolutely indifferent to others…likes to live for [their] pleasure today, does not make plans not only for the future but even for tomorrow, studying and working are not for them”. Persons with HLPD typically lack any deep knowledge, and “look for easy life and pleasures”. They have been described as “conquerers with an appearance of emotional warmth”.
Persons with HLPD were noted as struggling with hypochondria in 1907. They also struggle with alcoholism, and identify with antisocial personality disorder.
Kraepelin said they were “apt to take senseless journeys, perhaps even becoming vagabonds”. Kraepelin argued only lifelong wanderlust was tied to Haltlose, whereas Kahn argued that the Haltlose often lost their wanderlust as they aged and preferred to settle into mediocrity. Some make their fortune, but the disappearance of less fortunate travelers is not mentioned by their families who considered them to have been burdensome.
To early twentieth-century researchers, they appeared amiable, well-spoken, self-confident and to be making strong efforts to improve their weaknesses, thus making a misleading first impression and endearing themselves to superiors. The lack of a sense of identity, or internal support, was thought to a lack of resistance to both external and internal impulses in 1927. Their “gradual deterioration in the swamp of neediness and immorality” still does not make a lasting impression on the patients. Thus Haltlose patients who recognize their shortcomings were thought to possibly be overwhelmed by a subconscious fear about participating in the world without restraints in a 1924 account. Similarly, researchers in the early twentieth-century believed that the inauthenticity of their projected self and superficiality of knowledge means that when “someone who is really superior to [them]”, after a period of stiffly asserting themselves hoping to avoid submission, will ultimately and without explanation fully embrace the position of the other.
Pathological lying is closely linked to Haltlose personality disorder, with Arthur Kielholz noting “They lie like children…this activity always remains just a game which never satisfies them and leaves them with a guilty conscious because neither the super ego nor the Id get their due…Since they are offering such a daydream as a gift, they consider themselves entitled to extract some symbolic gift in return through fraud or theft”. Adler maintained “Memory is usually poor and untrustworthy…often they seem to have no realization of the truth”, while Homburger felt they held “no sense of objectivity, no need for truth or consistency”.
According to early accounts, choices are made, often in mirroring others around them, but “do not leave even a passing imprint on the person’s identity”. Thus, they can “behave properly for a while under good leadership”, and are not to be trusted in leadership positions themselves. Gannushkin noted they must be urged, scolded or encouraged “with a stick, as they say”. They demonstrate poor mood control and “react quickly to immediate circumstances” since “mood variation can be extreme and fluctuate wildly”, which led to the denotation “unstable psychopath”.
They have been described as “cold-blooded”, but must be differentiated from dependent personality disorder, as the two can appear similar, due to the artifice of the Haltlose patient, despite having starkly opposing foundations. Persons with Dependent Personality Disorder are defined by a tendency to embarrassment, and submissiveness which are not genuine facets of those with Haltlose even if they mimic such. Haltlose was thus deemed the “more troublesome” personality in 1955.
Childhood Origins, and Later Role of Family
“Whomever is abandoned in youth to the inexorable misery of existence, and at the same time is exposed to all manner of seductions, will find it very difficult to curb their constantly incited desires, and to instead force themselves through to the lofty vantage of moral self-assertion. Kraepelin speaking about the Haltlose, 1915.
It has been proposed that haltlose personality disorder may arise from “traumatization through maternal indolence” or institutionalisation in early life, although without definite conclusion. It may present in childhood simply as a hypomanic reaction to the loss of a parent or incest object. They often display a fear of abandonment that appeared in childhood, a common borderline personality disorder symptom. Male Haltlose personalities may come out of families with a pampering, over-protective and domineering mother with a weak father. Homburger noted the “childhood and youth of the Haltlose are extraordinarily sad”. It is possible, but rare, for Haltlose personalities to develop within healthy family structures.
Gerhardt Nissen referenced the possibility of intrauterine factors in the shaping of anti-social behaviours in Haltlose psychopaths, while noting the concept of psychopathy had been so weakened in modern psychopathology as to be indistinguishable from other conditions. Others have suggested there is a strong heredity correlation, as the parents often also display Haltlose personality disorder, especially the mother. Raising a haltlose child can, in some cases, destroy the family structure by forcing relatives to take opposing positions, provoking disagreement and creating an atmosphere of bitterness and dejection. They have been clinically described as disappointments to their families, and are unable to feel actual love for their parents and are indifferent to the hardships of relatives – since all relationships are seen only as potential means towards acquiring pleasure.
Care must be taken in making Haltlose diagnoses of children, since “the traits of instability of purpose, lack of forethought, suggestibility, egoism and superficiality of affect…are to some extent normal in childhood”. Children with haltlose personality disorder demonstrate a marked milieu dependency, which may be a cause rather than effect of the Haltlose. It is of great importance that only children with Haltlose have peers and friends to surround themselves to try and learn associations and behaviours. They often become sexually active at a young age but delayed sexual maturity, and as adults retain a psychophysical infantilism. Regressive addictions amongst Haltlose psychopaths typically are infantile, and seek to replace the lost “dual union” arising from their parents’ rejection, and later morph into a focus on subjects including vengeance or sado-masochism.
The age at which parents or professionals exhibited concern about psychopathy ranged; rarely even at a preschool age. Haltlose children confusingly tend to appear very strong-willed and ambitious, it is only as they age and the lack of perseverance becomes manifest that caretakers become puzzled by their “naughtiness” as it contradicts what had earlier appeared. This arises principally due to their rigid demands for short-term wishes being mistakenly interpreted as having a fixed purpose and persistence. Some patients later shown to be Haltlose, had shown neuropathic traits in childhood such as bedwetting and stuttering. They were also more likely to run away from their home, begin drinking before the socially acceptable age, and were afraid of punishment. Although struggling to make friends in young childhood, they find it easier as they age.
Kraepelin contended the disorder was “based on a biological predisposition” but also affected by factors such as childrearing practises, social position and state of the parental home. His analysis showed that 49% of diagnosed Haltlose had obvious parental issues such as alcoholism or personality disorders. A 1944 study of children produced by incest by Dr. Alfred Aschenbrenner found a high rate of Haltlose personality disorder, which he suggested might be explained as inherited from overly suggestive mothers. It is possible, although difficult, to diagnose from the age of five and presents one of the stronger psychiatric difficulties if present at such young age. It may be possible to prevent social failure “through welfare measures” akin to early intervention. Italian courts stressed mimicry of positive role models as a means to combat Haltlose youth who had fallen afoul of the law.
Haltlose can cause educational difficulties, and if parents do not understand the peculiarities of their haltlose child, they may try to through good intentions to force the child into an educational regimen inappropriate for them, which then creates a feeling of isolation in the child which grows into a rebellious tendencies, “which turns out to be disastrous for further development”. Students with Haltlose personalities may prefer the arts over the sciences, since the former does not require a consistent sense of truth and entails less disciplined study. Given their inability to anchor a self-schema and tendency to play-act roles, the theatre and film have great attraction and influence over them.
With proper leadership and controls from teachers, they are able to become “model pupils” in terms of behaviour, although Schneider opined that it was worthless to educate an inability to learn from mistakes prevented actual education, and bemoaned that the late onset of anti-social behaviours kept the Haltlose in school when they might otherwise be removed. Walter Moos believed that Haltlose personality disorder and hyperthymia had shown itself to be contagious in rare cases, wherein classmates developed the same disorder from interaction with patients. Homburger argued for removing a Haltlose child from their family of origin as soon as the disorder was confirmed, to resettle in a rural educational centre.
Adolescence, Young Adulthood and Efforts to Intervene
When required to live independently, they “soon lose interest, become distracted and absent-minded, and commit gross errors and negligence”. Ruth von der Leyen noted that “every care provider, teacher and doctor knows the Haltlose Psychopath from their practice”, and remarked that caring for such a patient was made more difficult because of the need to lecture and intervene to enlist the psychopath’s cooperation in short-term improvements, despite being aware the psychiatric reports have determined such efforts are ultimately useless but should be practised regardless.
The tendency to accumulate debts while seeking pleasure or escaping responsibility is often the attributed cause for their descent into crime, although Kramer noted those who displayed “extreme dexterity, sufficient talent for imagination, and a tendency towards dishonesty” were able to find alternative sources of income without necessarily becoming criminal, although warned that “again and again, their debts have to be paid until the parents no longer can, or want to, do this and leave them to their selves”.
Gannushkin noted “Such people involuntarily evoke sympathy and a desire to help them, but the assistance rendered to them rarely lasts, so it is worth abandoning such people for a short while”. The wasted good intentions resulted in the summary:
“probably the most important function of the psychiatrist when dealing with these patients is to protect their relatives and friends from ruining themselves in hopeless attempts at reclamation. With most of these patients a time comes when the relatives will be best advised…to allow the patient to go to prison, or otherwise suffer unsheltered the consequences of his deeds.”
By contrast, others have advanced the “rather optimistic” belief that “a suitable [spouse]” or similar “strong-willed” relative could drastically improve the outcome of Haltlosen patients. This was echoed by Andrey Yevgenyevich Lichko who, while preferring the term “accentuation of character” to describe the psychopathy rather than “personality disorder”, noted “if they fall into the hands of a person with a strong will, for example a wife or husband, they can they live quite happily…but the guardianship must be permanent.”
While some Haltlose have risen to the level of dangerous offenders multiple times over, it is more frequent that they attract attention early from their “vagabond” nature.
Heinrich Schulte, a wartime medical judge and consulting psychiatrist for the military, continued advocating for the sterilization of Haltlose and other “Schwachsinnigen” after the war’s end. In 1979, the Neue Anthropologie publication referred to a need to sterilize those like alcoholics, “who are often Haltlose psychopaths”, from bearing children, to reduce crime.
Although Kraepelin believed those with Haltlose personality disorder represented the antithesis of morality, there is not necessarily a tendency towards deliberate amorality among the demographic despite its frequent criminal violations since they may lack the ability to premeditate. But their demonstrated lack of self-control is “especially manifested in the sphere of morality”.
In 1935, it was estimated that 58% of recidivist criminals were diagnosed with Haltlose personality disorder, higher than any other personality disorder. More recently, Haltlose and Histrionic were the most common personality disorders found in female juvenile delinquents by forensic psychologists in Russia in the year 2000.
Domestic Violence, Incest and Molestation of Children
“[Patients resembling Haltlose] as a rule show little insight into the peculiarities of their conduct. They do not understand how they could have done these things, or they blame their relatives, neighbors and so forth”. Dr. Herman Morris Adler, 1917.
Although they enter relationships easily, Andrey Yevgenyevich Lichko contends they are not capable of actual loyalty or selfless love, and sex is treated as a form of entertainment rather than intimacy. They are therefore described as acting as “family tyrants”.
Although they may not qualify as “true” pedophiles, Haltlose personalities demonstrate an increased risk of sexually molesting children, since other potential victims would require the realisation of greater planning, but children are suggestible and easily overwhelmed.
A 1967 German study had suggested over 90% of adult-child incest offenders were diagnosed with Haltlose Personality Disorder. Female patients may also live vicariously through encouraging and directing the sexual lives of their daughters.
Drunk Driving, Hit-and-Run
Some Haltlose personalities are drawn towards dangerous driving habits “as a source of almost hedonist pleasure”. In 1949 the Automobil Revue proposed that additional tests should be necessary for Haltlose personalities to obtain a driver’s license. They have been known to steal cars to joyride at high speeds if they are not otherwise able to find satisfy their urge.
The American Journal of Psychiatry published a study of hit and run drivers in 1941, which showed 40% of drivers who fled the scene of a traffic accident tested positive for haltlose personality disorder. This was consistent with the earlier finding that Haltlose Personalities were among the most likely to attempt to flee if caught in commission of any crime.
Suicidality and Murder-Suicide
Research in the early twentieth century on suicidality among the Haltlose indicated several things: they chafe at the notion of any religion as it introduces unwanted inhibitions, especially against parasuicidal demonstrations; women Haltlose most frequently indicated suicidality was based upon fear of punishment or reproach, as well as the “excitement” of being institutionalised; and although frequently planning or attempting suicide, including through suicide pacts or murder suicide, Haltlose typically do not succeed since they lacked courage and were easily distracted.
Haltlose patients respond very well to institutionalization where their influences can be controlled, becoming “model inmates” of sanitariums even within hours of first arriving despite a chaotic life outside of the regimen, “but if you leave them, through good intentions, to their own devices – they don’t last long before collapsing their current state and being seduced back onto the wrong track”. Schneider recommended warning them “through punishing them” as it was the only control on their action. Bleuler said the court system needed to understand such persons were in “urgent need of inhibitions”.
Pyotr Gannushkin noted they joined military service due to peer pressure but given the lack of alcohol and stern, hard work required of them were able to function without their normal impairment. A 1942 study of the Wehrmacht found that only Haltlose and Schizoid were not measurable among soldiers despite their presence in the civilian population. A 1976 Soviet naval study came to similar conclusions.
Roth and Slater concluded “the treatment of such a personality is almost hopeless under the present ordering of society. Any treatment would…present difficulties…beyond the powers of these patients. The prospects of psychotherapy are forlorn and the best that can be obtained will be reached through social control.”
Some researchers suggest their moods and insufficient motivation will lead them to “vague feelings of fear and calamity…turning every little thing into big things, excitement, misinterpreting every harmless word, criticizing everything and commiting hostile acts”, and in some cases they look back with hindsight and regret the injustices they did. However Kramer held that when caught in wrongdoing, “we find them contrite, self-accusing and assuring that they will improve – but on closer inspection it is feigned and not sincere”.
Upon being confronted with their misdeeds, the Haltlose respond “with more or less superficial reasons to excuse them, they claim that their parents treated them incorrectly, that they were the victim of adverse circumstances, seduced by other people and misled. Other Haltlose, especially those with a strong intellect, make up a theoretical schema that would justify their actions.”
Kielholz, Arthur, Internationale Zeitschrift für Psychoanalyse XIX 1933 Heft 4, “Weh’dem der lugt! Beitrag zum problem der pseudologia phantastica”, an article on pathological lying in the Haltlose patients Max Specke, a Swiss charlatan with a penchant for melodramatic flair and Emil Schuldling, a habitual criminal with childhood sexual perversions
Story of Robert Wenger, who was diagnosed Haltlose and spent 54 years between institutions and prison for minor crimes until the documentary series Quer exposed his case, leading to an apology from politician Samuel Bhend in 1999.
Karl Hager, a habitual criminal diagnosed Haltlose who was frequently jailed for homosexual acts and was ultimately killed in Sachsenhausen concentration camp (in German)
Depressive personality disorder (also known as melancholic personality disorder) is a psychiatric diagnosis that denotes a personality disorder with depressive features.
Originally included in the American Psychiatric Association’s DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R. Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study. Although no longer listed as a personality disorder, the diagnosis is included under the section “personality disorder not otherwise specified”.
While depressive personality disorder shares some similarities with mood disorders such as dysthymia, it also shares many similarities with personality disorders including avoidant personality disorder. Some researchers argue that depressive personality disorder is sufficiently distinct from these other conditions so as to warrant a separate diagnosis.
The DSM-IV defines depressive personality disorder as “a pervasive pattern of depressive cognitions and behaviours beginning by early adulthood and occurring in a variety of contexts.” Depressive personality disorder occurs before, during, and after major depressive episodes (MDE), making it a distinct diagnosis not included in the definition of either MDE or dysthymic disorder. Specifically, five or more of the following must be present most days for at least two years in order for a diagnosis of depressive personality disorder to be made:
Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness and unhappiness.
Self-concept centres on beliefs of inadequacy, worthlessness and low self-esteem.
Is critical, blaming and derogatory towards the self.
Is brooding and given to worry.
Is negativistic, critical and judgmental toward others.
Is prone to feeling guilty or remorseful.
People with depressive personality disorder have a generally gloomy outlook on life, themselves, the past and the future. They are plagued by issues developing and maintaining relationships. In addition, studies have found that people with depressive personality disorder are more likely to seek psychotherapy than people with Axis I depression spectra diagnoses.
Recent studies have concluded that people with depressive personality disorder are at a greater risk of developing dysthymic disorder than a comparable group of people without depressive personality disorder. These findings lead to the fact that depressive personality disorder is a potential precursor to dysthymia or other depression spectrum diagnoses. If included in the DSM-V, depressive personality disorder would be included as a warning sign for potential development of more severe depressive episodes.
Theodore Millon identified five subtypes of depression. Any individual depressive may exhibit none, or one or more of the following:
Including negativistic features
1. Patients in this subtype are often hypochondriacal, cantankerous and irritable, and guilt-ridden and self-condemning. 2. In general, ill-humoured depressives are down on themselves and think the worst of everything.
Including histrionic and narcissistic features
1. Voguish depressives see unhappiness as a popular and stylish mode of social disenchantment, personal depression as self-glorifying, and suffering as ennobling. 2. The attention from friends, family, and doctors is seen as a positive aspect of the voguish depressive’s condition.
Including dependent features
1. Patients who fall under this subtype are self-deriding, discrediting, odious, dishonourable, and disparage themselves for weaknesses and shortcomings. 2. These patients blame themselves for not being good enough.
Including schizoid and masochistic features
1. Morbid depressives experience profound dejection and gloom, are highly lugubrious, and often feel drained and oppressed.
Including borderline and avoidant features
1. Patients who fall under this subtype are consistently unsettled, agitated, wrought in despair, and perturbed. 2. This is the subtype most likely to commit suicide in order to avoid all the despair in life.
Not all patients with a depressive disorder fall into a subtype. These subtypes are multidimensional in that patients usually experience multiple subtypes, instead of being limited to fitting into one subtype category. Currently, this set of subtypes is associated with melancholic personality disorders. All depression spectrum personality disorders are melancholic and can be looked at in terms of these subtypes.
Similarities to Dysthymic Disorder
Much of the controversy surrounding the potential inclusion of depressive personality disorder in the DSM-5 stems from its apparent similarities to dysthymic disorder, a diagnosis already included in the DSM-IV. Dysthymic disorder is characterised by a variety of depressive symptoms, such as hypersomnia or fatigue, low self-esteem, poor appetite, or difficulty making decisions, for over two years, with symptoms never numerous or severe enough to qualify as major depressive disorder. Patients with dysthymic disorder may experience social withdrawal, pessimism, and feelings of inadequacy at higher rates than other depression spectrum patients. Early-onset dysthymia is the diagnosis most closely related to depressive personality disorder.
The key difference between dysthymic disorder and depressive personality disorder is the focus of the symptoms used to diagnose. Dysthymic disorder is diagnosed by looking at the somatic senses, the more tangible senses. Depressive personality disorder is diagnosed by looking at the cognitive and intrapsychic symptoms. The symptoms of dysthymic disorder and depressive personality disorder may look similar at first glance, but the way these symptoms are considered distinguish the two diagnoses.
Comorbidity with other Disorders
Many researchers believe that depressive personality disorder is so highly comorbid with other depressive disorders, manic-depressive episodes and dysthymic disorder, that it is redundant to include it as a distinct diagnosis. Recent studies however, have found that dysthymic disorder and depressive personality disorder are not as comorbid as previously thought. It was found that almost two thirds of the test subjects with depressive personality disorder did not have dysthymic disorder, and 83% did not have early-onset dysthymia.
The comorbidity with Axis I depressive disorders is not as high as had been assumed. An experiment conducted by American psychologists showed that depressive personality disorder shows a high comorbidity rate with major depression experienced at some point in a lifetime and with any mood disorders experienced at any point in a lifetime. A high comorbidity rate with these disorders is expected of many diagnoses. As for the extremely high comorbidity rate with mood disorders, it has been found that essentially all mood disorders are comorbid with at least one other, especially when looking at a lifetime sample size.
Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterised by a long-term pattern of disregard for, or violation of, the rights of others. A weak or non-existent conscience is often apparent, as well as a history of legal problems or impulsive and aggressive behaviour.
Antisocial personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), while the equivalent concept of dissocial personality disorder (DPD) is defined in the International Statistical Classification of Diseases and Related Health Problems (ICD); the primary theoretical distinction between the two is that antisocial personality disorder focuses on observable behaviours, while dissocial personality disorder focuses on affective deficits. Otherwise, both manuals provide similar criteria for diagnosing the disorder. Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy. However, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.
The first version of the DSM in 1952 listed sociopathic personality disturbance. This category was for individuals who were considered “…ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals”. There were four subtypes, referred to as “reactions”: antisocial, dyssocial, sexual, and addiction. The antisocial reaction was said to include people who were “always in trouble” and not learning from it, maintaining “no loyalties”, frequently callous and lacking responsibility, with an ability to “rationalise” their behaviour. The category was described as more specific and limited than the existing concepts of “constitutional psychopathic state” or “psychopathic personality” which had had a very broad meaning; the narrower definition was in line with criteria advanced by Hervey M. Cleckley from 1941, while the term sociopathic had been advanced by George Partridge in 1928 when studying the early environmental influence on psychopaths. Partridge discovered the correlation between antisocial psychopathic disorder and parental rejection experienced in early childhood.
The DSM-II in 1968 rearranged the categories and “antisocial personality” was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: “basically unsocialised”, in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalise. The manual preface contains “special instructions” including “Antisocial personality should always be specified as mild, moderate, or severe.” The DSM-II warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a “group delinquent reaction” of childhood or adolescence or “social maladjustment without manifest psychiatric disorder” should be ruled out first. The dyssocial personality type was relegated in the DSM-II to “dyssocial behaviour” for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers. (DSM-I classified this condition as sociopathic personality disorder, dyssocial type). It would later resurface as the name of a diagnosis in the ICD manual produced by the WHO, later spelled dissocial personality disorder and considered approximately equivalent to the ASPD diagnosis.
The DSM-III in 1980 included the full term antisocial personality disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviours to enhance consistency in diagnosis between different psychiatrists (‘inter-rater reliability’). The ASPD symptom list was based on the Research Diagnostic Criteria developed from the so-called Feighner Criteria from 1972, and in turn largely credited to influential research by sociologist Lee Robins published in 1966 as “Deviant Children Grown Up”. However, Robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist Patricia O’Neal got the diagnostic criteria they used from Lee’s husband the psychiatrist Eli Robins, one of the authors of the Feighner criteria who had been using them as part of diagnostic interviews.
The DSM-IV maintained the trend for behavioural antisocial symptoms while noting “This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder” and re-including in the ‘Associated Features’ text summary some of the underlying personality traits from the older diagnoses. The DSM-5 has the same diagnosis of antisocial personality disorder. The Pocket Guide to the DSM-5 Diagnostic Exam suggests that a person with ASPD may present “with psychopathic features” if he or she exhibits “a lack of anxiety or fear and a bold, efficacious interpersonal style”.
As seen in two North American studies and two European studies, ASPD is more commonly seen in men than in women, with men three to five times more likely to be diagnosed with ASPD than women. The prevalence of ASPD is even higher in selected populations, like prisons, where there is a preponderance of violent offenders. It has been found that the prevalence of ASPD among prisoners is just under 50%. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) use treatment programmes than in the general population, suggesting a link between ASPD and AOD use and dependence. As part of the Epidemiological Catchment Area (ECA) study, men with ASPD were found to be three to five times more likely to excessively use alcohol and illicit substances than those men without ASPD. While ASPD occurs more often in men than women, there was found to be increased severity of this substance use in women with ASPD. In a study conducted with both men and women with ASPD, women were more likely to misuse substances compared to their male counterparts.
Individuals with ASPD are at an elevated risk for suicide. Some studies suggest this increase in suicidality is in part due to the association between suicide and symptoms or trends within ASPD, such as criminality and substance use. Offspring of ASPD victims are also at risk. Some research suggests that negative or traumatic experiences in childhood, perhaps as a result of the choices a parent with ASPD might make, can be a predictor of delinquency later on in the child’s life. Additionally, with variability between situations, children of a parent with ASPD may suffer consequences of delinquency if they’re raised in an environment in which crime and violence is common. Suicide is a leading cause of death among youth who display antisocial behaviour, especially when mixed with delinquency. Incarceration, which could come as a consequence of actions from a victim of ASPD, is a predictor for suicide ideation in youth.
Signs and Symptoms
Antisocial personality disorder is defined by a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others. Individuals with this personality disorder will typically have no compunction in exploiting others in harmful ways for their own gain or pleasure and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence. They may display arrogance, think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude to those they have harmed. Irresponsibility is a core characteristic of this disorder; most have significant difficulties in maintaining stable employment as well as fulfilling their social and financial obligations, and people with this disorder often lead exploitative, unlawful, or parasitic lifestyles.
Those with antisocial personality disorder are often impulsive and reckless, failing to consider or disregarding the consequences of their actions. They may repeatedly disregard and jeopardise their own safety and the safety of others, which can place both themselves and other people in danger. They are often aggressive and hostile, with poorly regulated tempers, and can lash out violently with provocation or frustration. Individuals are prone to substance use disorders and addiction, and the non-medical use of various psychoactive substances is common in this population. These behaviours lead such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behaviour and criminal infractions stemming back to adolescence or childhood.
Serious problems with interpersonal relationships are often seen in those with the disorder. People with antisocial personality disorder usually form poor attachments and emotional bonds, and interpersonal relationships often revolve around the exploitation and abuse of others. They may have difficulties in sustaining and maintaining relationships, and some have difficulty entering them.
While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood. The DSM-5’s criteria for ASPD require that the individual have conduct problems evident by the age of 15. Persistent antisocial behaviour, as well as a lack of regard for others in childhood and adolescence, is known as conduct disorder and is the precursor of ASPD. About 25-40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.
Conduct disorder (CD) is a disorder diagnosed in childhood that parallels the characteristics found in ASPD and is characterised by a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate norms are violated. Children with the disorder often display impulsive and aggressive behaviour, may be callous and deceitful, and may repeatedly engage in petty crime such as stealing or vandalism or get into fights with other children and adults. This behaviour is typically persistent and may be difficult to deter with threat or punishment. Attention deficit hyperactivity disorder (ADHD) is common in this population, and children with the disorder may also engage in substance use. CD is differentiated from oppositional defiant disorder (ODD) in that children with ODD do not commit aggressive or antisocial acts against other people, animals, and property, though many children diagnosed with ODD are subsequently re-diagnosed with CD.
Two developmental courses for CD have been identified based on the age at which the symptoms become present. The first is known as the “childhood-onset type” and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviours, and children in this group express greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence. The second is known as the “adolescent-onset type” and occurs when conduct disorder develops after the age of 10 years. Compared to the childhood-onset type, less impairment in various cognitive and emotional functions are present, and the adolescent-onset variety may remit by adulthood. In addition to this differentiation, the DSM-5 provides a specifier for a callous and unemotional interpersonal style, which reflects characteristics seen in psychopathy and are believed to be a childhood precursor to this disorder. Compared to the adolescent-onset subtype, the childhood-onset subtype, especially if callous and unemotional traits are present, tends to have a worse treatment outcome.
ASPD commonly coexists with the following conditions:
Impulse control disorders.
Attention deficit hyperactivity disorder.
Borderline personality disorder.
Histrionic personality disorder.
Narcissistic personality disorder.
Sadistic personality disorder.
When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition. Alcohol Use Disorder is likely caused by lack of impulse and behavioural control exhibited by Antisocial Personality Disorder patients. The rates of ASPD tends to be around 40-50% in male alcohol and opiate addicts. However, it is important to remember this is not a causal relationship, but rather a plausible consequence of cognitive deficits as a result of ASPD.
Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences. Genetically, it is the intrinsic temperamental tendencies as determined by their genetically influenced physiology, and environmentally, it is the social and cultural experiences of a person in childhood and adolescence encompassing their family dynamics, peer influences, and social values. People with an antisocial or alcoholic parent are considered to be at higher risk. Fire-setting and cruelty to animals during childhood are also linked to the development of antisocial personality. The condition is more common in males than in females, and among people who are in prison.
Research into genetic associations in antisocial personality disorder suggests that ASPD has some or even a strong genetic basis. Prevalence of ASPD is higher in people related to someone afflicted by the disorder. Twin studies, which are designed to discern between genetic and environmental effects, have reported significant genetic influences on antisocial behaviour and conduct disorder.
In the specific genes that may be involved, one gene that has seen particular interest in its correlation with antisocial behaviour is the gene that encodes for Monoamine oxidase A (MAO-A), an enzyme that breaks down monoamine neurotransmitters such as serotonin and norephinephrine. Various studies examining the genes’ relationship to behaviour have suggested that variants of the gene that results in less MAO-A being produced, such as the 2R and 3R alleles of the promoter region, have associations with aggressive behaviour in men. The association is also influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) who experience such maltreatment being more likely to develop antisocial behaviour than those with the high-activity variant (MAOA-H). Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behaviour remains.
The gene that encodes for the serotonin transporter (SCL6A4), a gene that is heavily researched for its associations with other mental disorders, is another gene of interest in antisocial behaviour and personality traits. Genetic associations studies have suggested that the short “S” allele is associated with impulsive antisocial behaviour and ASPD in the inmate population. However, research into psychopathy find that the long “L” allele is associated with the Factor 1 traits of psychopathy, which describes its core affective (e.g. lack of empathy, fearlessness) and interpersonal (e.g. grandiosity, manipulativeness) personality disturbances. This is suggestive of two different forms, one associated more with impulsive behaviour and emotional dysregulation, and the other with predatory aggression and affective disturbance, of the disorder.
Various other gene candidates for ASPD have been identified by a genome-wide association study published in 2016. Several of these gene candidates are shared with attention-deficit hyperactivity disorder, with which ASPD is comorbid. Furthermore, the study found that those who carry 4 mutations on chromosome 6 are 1.5 times more likely to develop antisocial personality disorder than those who do not.
Hormones and Neurotransmitters
Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain. For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person. The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.
One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT. A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.
While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism, but may be the most essential psychopathological aspect linked with such dysfunction. Correspondingly, the DSM classifies “impulsivity or failure to plan ahead” and “irritability and aggressiveness” as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.
Some studies have found a relationship between monoamine oxidase A and antisocial behaviour, including conduct disorder and symptoms of adult ASPD, in maltreated children.
Antisocial behaviour may be related to head trauma. Antisocial behaviour is associated with decreased grey matter in the right lentiform nucleus, left insula, and frontopolar cortex. Increased volumes have been observed in the right fusiform gyrus, inferior parietal cortex, right cingulate gyrus, and post central cortex.
Intellectual and cognitive ability is consistently found to be impaired or reduced in the ASPD population. Contrary to stereotypes in popular culture of the “psychopathic genius”, antisocial personality disorder is associated with both reduced overall intelligence and specific reductions in individual aspects of cognitive ability. These deficits also occur in general-population samples of people with antisocial traits and in children with the precursors to antisocial personality disorder.
People that exhibit antisocial behaviour demonstrate decreased activity in the prefrontal cortex. The association is more apparent in functional neuroimaging as opposed to structural neuroimaging. The prefrontal cortex is involved in many executive functions, including behaviour inhibitions, planning ahead, determining consequences of action, and differentiating between right and wrong. However, some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment. Moreover, it remains an open question whether the relationship is causal, i.e. whether the anatomical abnormality causes the psychological and behavioural abnormality, or vice versa.
Cavum septi pellucidi (CSP) is a marker for limbic neural maldevelopment, and its presence has been loosely associated with certain mental disorders, such as schizophrenia and post-traumatic stress disorder. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.
Some studies suggest that the social and home environment has contributed to the development of antisocial behaviour. The parents of these children have been shown to display antisocial behaviour, which could be adopted by their children. A lack of parental stimulation and affection during early development leads to sensitization of the child’s stress response systems, which is thought to lead to underdevelopment of the child’s brain that deals with emotion, empathy and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, “the [infant’s developing] brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a baby’s stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child.”
The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders such as ASPD are viewed differently. Robert D. Hare has suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioural tendencies of many individuals with ASPD. While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques, given Eric Berne’s division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion – it has been suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behaviour.
There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD. Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He states that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with it could be potentially disastrous, but the possibility of not diagnosing it and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore, and in his words, “play it safe”.
It is characterised by at least 3 of the following:
Callous unconcern for the feelings of others;
Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
Incapacity to maintain enduring relationships, though having no difficulty in establishing them;
Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
Incapacity to experience guilt or to profit from experience, particularly punishment; and/or
Marked readiness to blame others or to offer plausible rationalisations for the behaviour that has brought the person into conflict with society.
The ICD states that this diagnosis includes “amoral, antisocial, asocial, psychopathic, and sociopathic personality”. Although the disorder is not synonymous with conduct disorder, presence of conduct disorder during childhood or adolescence may further support the diagnosis of dissocial personality disorder. There may also be persistent irritability as an associated feature.
It is a requirement of the ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Psychopathy is commonly defined as a personality disorder characterised partly by antisocial behaviour, a diminished capacity for empathy and remorse, and poor behavioural controls. Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare’s Psychopathy Checklist, Revised (PCL-R). “Psychopathy” is not the official title of any diagnosis in the DSM or ICD; nor is it an official title used by other major psychiatric organisations. The DSM and ICD, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy.
American psychiatrist Hervey Cleckley’s work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy. However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed such traits were difficult to measure reliably and it was “easier to agree on the behaviours that typify a disorder than on the reasons why they occur”.
Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. He suggests there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on “processing and use of linguistic and emotional information”, while such differences are potentially smaller between those diagnosed with ASPD and without. Additionally, Hare argued confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.
Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under “Alternative DSM-5 Model for Personality Disorders”, ASPD with psychopathic features is described as characterised by “a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviours (e.g. fraudulence).” Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with “social potency” and “stress immunity” in psychopathy. Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioural components.
ASPD is considered to be among the most difficult personality disorders to treat. Rendering an effective treatment for ASPD is further complicated due to the inability to look at comparative studies between psychopathy and ASPD due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.
Most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. Those with ASPD may stay in treatment only as required by an external source, such as parole conditions. Residential programmes that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions. Psychotherapy also known as talk therapy is found to help treat patients with ASPD. Schema therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of Multisystemic therapy (MST) that could potentially improve this imperative issue. However, this treatment requires complete cooperation and participation of all family members. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance use, although others have reported contradictory findings.
Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviours. Rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behaviour and abstaining from antisocial behaviour. However, the impulsive and aggressive nature of those with this disorder may limit the effectiveness of even this form of therapy.
The use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the FDA to specifically treat ASPD. A 2020 Cochrane review of studies that explored the use of pharmaceuticals in ASPD patients, of which 8 studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of ASPD. Nonetheless, psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with ASPD for which medications are indicated.
According to Professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience there are many variables that are consistently connected to ASPD, such as: childhood hyperactivity and conduct disorder, criminality in adulthood, lower IQ scores and reading problems. The strongest relationship between these variables and ASPD are childhood hyperactivity and conduct disorder. Additionally, children who grow up with a predisposition of ASPD and interact with other delinquent children are likely to later be diagnosed with ASPD. Like many disorders, genetics play a role in this disorder but the environment holds an undeniable role in its development.
Boys are twice as likely to meet all of the diagnostic criteria for ASPD than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. Children that do not show symptoms of the disease through age 15 will not develop ASPD later in life. If adults exhibit milder symptoms of ASPD, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. Overall, symptoms of ASPD tend to peak in late-teens and early twenties, but can often reduce or improve through age 40.
ASPD is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. There may be a high variability of the long-term outlook of antisocial personality disorder. The treatment of this disorder can be successful, but it entails unique difficulties. It is unlikely to see rapid change especially when the condition is severe. In fact, past studies revealed that remission rates were small, with up to only 31% rates of improvement instead of remittance. As a result of the characteristics of ASPD (e.g. displaying charm in effort of personal gain, manipulation), patients seeking treatment (mandated or otherwise) may appear to be “cured” in order to get out of treatment. According to definitions found in the DSM-5, people with ASPD can be deceitful and intimidating in their relationships. When they are caught doing something wrong, they often appear to be unaffected and unemotional about the consequences. Over time, continual behaviour that lacks empathy and concern may lead to someone with ASPD taking advantage of the kindness of others, including his or her therapist.
Without proper treatment, individuals suffering with ASPD could lead a life that brings about harm to themselves or others. This can be detrimental to their families and careers. ASPD victims suffer from lack of interpersonal skills (e.g. lack of remorse, lack of empathy, lack of emotional-processing skills). As a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with ASPD may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide. They also see higher rates of committed crime, reaching peaks in their late teens and often committing higher-severity crimes in their younger ages of diagnoses. Comorbidity of other mental illnesses such as Depression or substance use disorder is prevalent among ASPD victims. People with ASPD are also more likely to commit homicides and other crimes. Those who are imprisoned longer often see higher rates of improvement with symptoms of ASPD than others who have been imprisoned for a shorter amount of time.
According to one study, aggressive tendencies show in about 72% of all male patients diagnosed with ASPD. About 29% of the men studied with ASPD also showed a prevalence of pre-meditated aggression. Based on the evidence in the study, the researchers concluded that aggression in patients with ASPD is mostly impulsive, though there are some long-term evidences of pre-meditated aggressions. It often occurs that those with higher psychopathic traits will exhibit the pre-meditated aggressions to those around them. Over the course of a patient’s life with ASPD, he or she can exhibit this aggressive behaviour and harm those close to him or her.
Additionally, many people (especially adults) who have been diagnosed with ASPD become burdens to their close relatives, peers, and caretakers. Harvard Medical School recommends that time and resources be spent treating victims who have been affected by someone with ASPD, because the patient with ASPD may not respond to the administered therapies. In fact, a patient with ASPD may only accept treatment when ordered by a court, which will make their course of treatment difficult and severe. Because of the challenges in treatment, the patient’s family and close friends must take an active role in decisions about therapies that are offered to the patient. Ultimately, there must be a group effort to aid the long-term effects of the disorder.
Dependent personality disorder (DPD) is a personality disorder that is characterised by a pervasive psychological dependence on other people.
This personality disorder is a long-term condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. Dependent personality disorder is a Cluster C personality disorder, characterised by excessive fear and anxiety. It begins by early adulthood, and it is present in a variety of contexts and is associated with inadequate functioning. Symptoms can include anything from extreme passivity, devastation or helplessness when relationships end, avoidance of responsibilities and severe submission.
The conceptualisation of dependency, within classical psychoanalytic theory, is directly related to Freud’s oral psychosexual stage of development. Frustration or over-gratification was said to result in an oral fixation and in an oral type of character, characterised by feeling dependent on others for nurturance and by behaviours representative of the oral stage. Later psychoanalytic theories shifted the focus from a drive-based approach of dependency to the recognition of the importance of early relationships and establishing separation from these early caregivers, in which the exchanges between the caregiver and the child become internalised, and the nature of these interactions becomes part of the concepts of the self and of others.
Signs and Symptoms
People who have dependent personality disorder are overdependent on other people when it comes to making decisions. They cannot make a decision on their own as they need constant approval from other people. Consequently, individuals diagnosed with DPD tend to place needs and opinions of others above their own as they do not have the confidence to trust their decisions. This kind of behaviour can explain why people with DPD tend to show passive and clingy behaviour. These individuals display a fear of separation and cannot stand being alone. When alone, they experience feelings of isolation and loneliness due to their overwhelming dependence on other people. Generally people with DPD are also pessimistic: they expect the worst out of situations or believe that the worst will happen. They tend to be more introverted and are more sensitive to criticism and fear rejection.
People with a history of neglect and an abusive upbringing are more susceptible to develop DPD, specifically those involved in long-term abusive relationships. Those with overprotective or authoritarian parents are also more at risk to develop DPD. Having a family history of anxiety disorder can play a role in the development of DPD as a 2004 twin study found a 0.81 heritability for personality disorders collectively.
The exact cause of dependent personality disorder is unknown. A study in 2012 estimated that between 55% and 72% of the risk of the condition is inherited from one’s parents. The difference between a “dependent personality” and a “dependent personality disorder” is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations.
Dependent traits in children tended to increase with parenting behaviours and attitudes characterized by overprotectiveness and authoritarianism. Thus the likelihood of developing dependent personality disorder increased, since these parenting traits can limit them from developing a sense of autonomy, rather teaching them that others are powerful and competent.
Traumatic or adverse experiences early in an individual’s life, such as neglect and abuse or serious illness, can increase the likelihood of developing personality disorders, including dependent personality disorder, later on in life. This is especially prevalent for those individuals who also experience high interpersonal stress and poor social support.
There is a higher frequency of the disorder seen in women than men, hence expectations relating to gender role may contribute to some extent.
Clinicians and clinical researchers conceptualise dependent personality disorder in terms of four related components:
Cognitive: a perception of oneself as powerless and ineffectual, coupled with the belief that other people are comparatively powerful and potent.
Motivational: a desire to obtain and maintain relationships with protectors and caregivers.
Behavioural: a pattern of relationship-facilitating behaviour designed to strengthen interpersonal ties and minimise the possibility of abandonment and rejection.
Emotional: fear of abandonment, fear of rejection, and anxiety regarding evaluation by figures of authority.
American Psychiatric Association and DSM
The Diagnostic and Statistical Manual of Mental Disorders (DSM) contains a dependent personality disorder diagnosis. It refers to a pervasive and excessive need to be taken care of which leads to submissive and clinging behaviour and fears of separation. This begins by early adulthood and can be present in a variety of contexts.
In the DSM Fifth Edition (DSM-5), there is one criterion by which there are eight features of dependent personality disorder. The disorder is indicated by at least five of the following factors:
Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
Needs others to assume responsibility for most major areas of their life.
Has difficulty expressing disagreement with others because of fear of loss of support or approval.
Has difficulty initiating projects or doing things on their own (because of a lack of self confidence in judgement or abilities rather than a lack of motivation or energy).
Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themselves.
Urgently seeks another relationship as a source of care and support when a close relationship ends.
Is unrealistically preoccupied with fears of being left to take care of themselves.
The diagnosis of personality disorders in the fourth edition the DSM, including dependent personality disorder, was found to be problematic due to reasons such as excessive diagnostic comorbidity, inadequate coverage, arbitrary boundaries with normal psychological functioning, and heterogeneity among individuals within the same categorial diagnosis.
World Health Organisation
The World Health Organisation’s (WHO) ICD-10 lists dependent personality disorder as F60.7 Dependent personality disorder:
It is characterised by at least 4 of the following:
Encouraging or allowing others to make most of one’s important life decisions;
Subordination of one’s own needs to those of others on whom one is dependent, and undue compliance with their wishes;
Unwillingness to make even reasonable demands on the people one depends on;
Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself;
Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;
Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.
Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina.
Asthenic, inadequate, passive, and self-defeating personality (disorder).
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
The SWAP-200 is a diagnostic tool that was proposed with the goal of overcoming limitations, such as limited external validity for the diagnostic criteria for dependent personality disorder, to the DSM. It serves as a possible alternative nosological system that emerged from the efforts to create an empirically based approach to personality disorders – while also preserving the complexity of clinical reality. Dependent personality disorder is considered a clinical prototype in the context of the SWAP-200. Rather than discrete symptoms, it provides composite description characteristic criteria – such as personality tendencies.
Based on the Q-Sort method and prototype matching, the SWAP-200 is a personality assessment procedure relying on an external observer’s judgment. It provides:
A personality diagnosis expressed as the matching with ten prototypical descriptions of DSM-IV personality disorders.
A personality diagnosis based on the matching of the patient with 11 Q-factors of personality derived empirically.
A dimensional profile of healthy and adaptive functioning.
The traits that define dependent personality disorder according to SWAP-200 are:
They tend to become attached quickly and/or intensely, developing feelings and expectations that are not warranted by the history or context of the relationship.
Since they tend to be ingratiating and submissive, people with DPD tend to be in relationships in which they are emotionally or physically abused.
They tend to feel ashamed, inadequate, and depressed.
They also feel powerless and tend to be suggestible.
They are often anxious and tend to feel guilty.
These people have difficulty acknowledging and expressing anger and struggle to get their own needs and goals met.
Unable to soothe or comfort themselves when distressed, they require involvement of another person to help regulate their emotions.
Psychodynamic Diagnostic Manual
The Psychodynamic Diagnostic Manual (PDM) approaches dependent personality disorder in a descriptive, rather than prescriptive sense and has received empirical support. The Psychodynamic Diagnostic Manual includes two different types of dependent personality disorder:
The PDM-2 adopts and applies a prototypic approach, using empirical measures like the SWAP-200. It was influenced by a developmental and empirically grounded perspective, as proposed by Sidney Blatt. This model is of particular interest when focusing on dependent personality disorder, claiming that psychopathology comes from distortions of two main coordinates of psychological development:
The anaclitic/introjective dimension.
The relatedness/self-definition dimension.
The anaclitic personality organization in individuals exhibits difficulties in interpersonal relatedness, exhibiting the following behaviours:
Preoccupation with relationships.
Fear of abandonment and of rejection.
Seeking closeness and intimacy.
Difficulty managing interpersonal boundaries.
Tend to have an anxious-preoccupied attachment style.
Introjective personality style is associated with problems in self-definition.
There are similarities between individuals with dependent personality disorder and individuals with borderline personality disorder, in that they both have a fear of abandonment. Those with dependent personality disorder do not exhibit impulsive behaviour, unstable affect, and poor self-image experienced by those with borderline personality disorder, differentiating the two disorders.
The following conditions commonly coexist (comorbid) with dependent personality disorder:
People who have DPD are generally treated with psychotherapy. The main goal of this therapy is to make the individual more independent and help them form healthy relationships with the people around them. This is done by improving their self-esteem and confidence.
Medication can be used to treat patients who suffer from depression or anxiety because of their DPD, but this does not treat the core problems caused by DPD. Individuals who take these prescription drugs are susceptible to addiction and substance abuse and therefore may require monitoring.
Based on a recent survey of 43,093 Americans, 0.49% of adults meet diagnostic criteria for DPD (National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Grant et al., 2004). Traits related to DPD, like most personality disorders emerge in childhood or early adulthood. Findings from the NESArC study found that 18 to 29 year olds have a greater chance of developing DPD. DPD is more common among women compared to men as 0.6% of women have DPD compared to 0.4% of men.
A 2004 twin study suggests a heritability of 0.81 for developing dependent personality disorder. Because of this, there is significant evidence that this disorder runs in families.
Children and adolescents with a history of anxiety disorders and physical illnesses are more susceptible to acquiring this disorder.
Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterised by a pattern of excessive attention-seeking behaviours, usually beginning in early childhood, including inappropriate seduction and an excessive desire for approval.
Individuals diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, and flirtatious. Women are diagnosed with HPD roughly 4 times as often as men. It affects 2-3% of the general population and 10-15% in inpatient and outpatient mental health institutions.
HPD lies in the dramatic cluster of personality disorders. People with HPD have a high desire for attention, make loud and inappropriate appearances, exaggerate their behaviours and emotions, and crave stimulation. They may exhibit sexually provocative behaviour, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behaviour to achieve their own needs.
Signs and Symptoms
People with HPD are usually high-functioning, both socially and professionally. They usually have good social skills, despite tending to use them to manipulate others into making them the centre of attention. HPD may also affect a person’s social and romantic relationships, as well as their ability to cope with losses or failures. They may seek treatment for clinical depression when romantic (or other close personal) relationships end.
Individuals with HPD often fail to see their own personal situation realistically, instead dramatising and exaggerating their difficulties. They may go through frequent job changes, as they become easily bored and may prefer withdrawing from frustration (instead of facing it). Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing clinical depression.
Additional characteristics may include:
Constant seeking of reassurance or approval.
Excessive sensitivity to criticism or disapproval.
Pride of own personality and unwillingness to change, viewing any change as a threat.
Inappropriately seductive appearance or behaviour of a sexual nature.
Using factitious somatic symptoms (of physical illness) or psychological disorders to garner attention.
Low tolerance for frustration or delayed gratification.
Rapidly shifting emotional states that may appear superficial or exaggerated to others.
Tendency to believe that relationships are more intimate than they actually are.
Making rash decisions.
Blaming personal failures or disappointments on others.
Being easily influenced by others, especially those who treat them approvingly.
Being overly dramatic and emotional.
Influenced by the suggestions of others.
Some people with histrionic traits or personality disorder change their seduction technique into a more maternal or paternal style as they age.
A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as “PRAISE ME”:
Provocative (or seductive) behaviour.
Relationships are considered more intimate than they actually are.
Influenced easily by others or circumstances.
Speech (style) wants to impress; lacks detail.
Emotional lability; shallowness.
Make-up; physical appearance is used to draw attention to self.
Exaggerated emotions; theatrical.
Little research has been done to find evidence of what causes histrionic personality disorder. Although direct causes are inconclusive, various theories and studies suggest multiple possible causes, of a neurochemical, genetic, psychoanalytic, or environmental nature. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women diagnosed with HPD. HPD symptoms typically do not fully develop until the age of 15, while the onset of treatment only occurs, on average, at approximately 40 years of age.
Studies have shown that there is a strong correlation between the function of neurotransmitters and the Cluster B personality disorders such as HPD. Individuals diagnosed with HPD have highly responsive noradrenergic systems which is responsible for the synthesis, storage, and release of the neurotransmitter, norepinephrine. High levels of norepinephrine leads to anxiety-proneness, dependency, and high sociability.
Twin studies have aided in breaking down the genetic vs. environment debate. A twin study conducted by the Department of Psychology at Oslo University attempted to establish a correlation between genetic and Cluster B personality disorders. With a test sample of 221 twins, 92 monozygotic and 129 dizygotic, researchers interviewed the subjects using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and concluded that there was a correlation of 0.67 that histrionic personality disorder is hereditary.
Though criticised as being unsupported by scientific evidence, psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet. Using psychoanalysis, Freud believed that lustfulness was a projection of the patient’s lack of ability to love unconditionally and develop cognitively to maturity, and that such patients were overall emotionally shallow. He believed the reason for being unable to love could have resulted from a traumatic experience, such as the death of a close relative during childhood or divorce of one’s parents, which gave the wrong impression of committed relationships. Exposure to one or multiple traumatic occurrences of a close friend or family member’s leaving (via abandonment or mortality) would make the person unable to form true and affectionate attachments towards other people.
HPD and Antisocial Personality Disorder
Another theory suggests a possible relationship between histrionic personality disorder and antisocial personality disorder. Research has found 2/3 of patients diagnosed with histrionic personality disorder also meet criteria similar to those of the antisocial personality disorder, which suggests both disorders based towards sex-type expressions may have the same underlying cause. Women are hypersexualised in the media consistently, ingraining thoughts that the only way women are to get attention is by exploiting themselves, and when seductiveness is not enough, theatrics are the next step in achieving attention. Men can just as well be flirtatious towards multiple women yet feel no empathy or sense of compassion towards them. They may also become the centre of attention by exhibiting the “Don Juan” macho figure as a role-play.
Some family history studies have found that histrionic personality disorder, as well as borderline and antisocial personality disorders, tend to run in families, but it is unclear if this is due to genetic or environmental factors. Both examples suggest that predisposition could be a factor as to why certain people are diagnosed with histrionic personality disorder, however little is known about whether or not the disorder is influenced by any biological compound or is genetically inheritable. Little research has been conducted to determine the biological sources, if any, of this disorder.
The person’s appearance, behaviour and history, along with a psychological evaluation, are usually sufficient to establish a diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed.
A pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Is uncomfortable in situations in which he or she is not the centre of attention.
Interaction with others is often characterised by inappropriate sexually seductive or provocative behaviour.
Displays rapidly shifting and shallow expression of emotions.
Consistently uses physical appearance to draw attention to self.
Has a style of speech that is excessively impressionistic and lacking in detail.
Shows self-dramatisation, theatricality, and exaggerated expression of emotion.
Is suggestible, i.e. easily influenced by others or circumstances.
Considers relationships to be more intimate than they actually are.
The DSM 5 requires that a diagnosis for any specific personality disorder also satisfies a set of general personality disorder criteria.
The World Health Organization’s ICD-10 lists histrionic personality disorder as:
A personality disorder characterised by:
Shallow and labile affectivity.
Exaggerated expression of emotions.
Lack of consideration for others.
Easily hurt feelings.
Continuous seeking for appreciation, excitement and attention.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Most histrionics also have other mental disorders. Comorbid conditions include: antisocial, dependent, borderline, and narcissistic personality disorders, as well as depression, anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder and attachment disorders, including reactive attachment disorder.
Theodore Millon identified six subtypes of histrionic personality disorder. Any individual histrionic may exhibit none or one of the following (as outlined in the table below).
Including dependent and compulsive features.
Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.
The seductiveness of the histrionic mixed with the energy typical of hypomania. Some narcissistic features can also be present.
Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.
Including borderline features.
Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.
Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression. The only successful method studied and proven to succeed is to fully break contact with their lovers in order to gain a sense of stability and independence once again. Treatment for HPD itself involves psychotherapy, including cognitive therapy.
Interviews and Self-Report Methods
In general clinical practice with assessment of personality disorders, one form of interview is the most popular; an unstructured interview. The actual preferred method is a semi-structured interview but there is reluctance to use this type of interview because they can seem impractical or superficial. The reason that a semi-structured interview is preferred over an unstructured interview is that semi-structured interviews tend to be more objective, systematic, replicable, and comprehensive. Unstructured interviews, despite their popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the client.
One of the single most successful methods for assessing personality disorders by researchers of normal personality functioning is the self-report inventory following up with a semi-structured interview. There are some disadvantages with the self-report inventory method that with histrionic personality disorder there is a distortion in character, self-presentation, and self-image. This cannot be assessed simply by asking most clients if they match the criteria for the disorder. Most projective testing depend less on the ability or willingness of the person to provide an accurate description of the self, but there is currently limited empirical evidence on projective testing to assess histrionic personality disorder.
Functional Analytic Psychotherapy
Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy. The job of a Functional Analytic Psychotherapist is to identify the interpersonal problems with the patient as they happen in session or out of session. Initial goals of functional analytic psychotherapy are set by the therapist and include behaviours that fit the client’s needs for improvement. Functional analytic psychotherapy differs from the traditional psychotherapy due to the fact that the therapist directly addresses the patterns of behaviour as they occur in-session.
The in-session behaviours of the patient or client are considered to be examples of their patterns of poor interpersonal communication and to adjust their neurotic defences. To do this, the therapist must act on the client’s behaviour as it happens in real time and give feedback on how the client’s behaviour is affecting their relationship during therapy. The therapist also helps the client with histrionic personality disorder by denoting behaviours that happen outside of treatment; these behaviours are termed “Outside Problems” and “Outside Improvements”. This allows the therapist to assist in problems and improvements outside of session and to verbally support the client and condition optimal patterns of behaviour. This then can reflect on how they are advancing in-session and outside of session by generalising their behaviours over time for changes or improvement.
Coding Client and Therapist Behaviours
This is called coding client and therapist behaviour. In these sessions there is a certain set of dialogue or script that can be forced by the therapist for the client to give insight on their behaviours and reasoning. Here is an example a hypothetical conversation. T = therapist C = Client. This coded dialogue can be transcribed as:
ECRB – Evoking clinically relevant behaviour:
T: Tell me how you feel coming in here today (CRB2).
C: Well, to be honest, I was nervous. Sometimes I feel worried about how things will go, but I am really glad I am here.
CRB1 – In-session problems:
C: Whatever, you always say that. (becomes quiet). I don’t know what I am doing talking so much.
CRB2 – In-session improvements.
TCRB1 – Clinically relevant response to client problems.
T: Now you seem to be withdrawing from me. That makes it hard for me to give you what you might need from me right now. What do you think you want from me as we are talking right now?”.
TCRB2 – Responses to client improvement:
T: That’s great. I am glad you’re here, too. I look forward to talking to you.
Functional Ideographic Assessment Template
Another example of treatment besides coding is functional ideographic assessment template. The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy. The template was made by a combined effort of therapists and can be used to represent the behaviours that are a focus for this treatment. Using the FIAT therapists can create a common language to get stable and accurate communication results through functional analytic psychotherapy at the ease of the client; as well as the therapist.
The survey data from the National epidemiological survey from 2001-2002 suggests a prevalence of HPD of 1.84%. Major character traits may be inherited, while other traits may be due to a combination of genetics and environment, including childhood experiences. This personality is seen more often in women than in men. Approximately 65% of HPD diagnoses are women while 35% are men. In Marcie Kaplan’s A Women’s View of DSM-III, she argues that women are overdiagnosed due to potential biases and expresses that even healthy women are often automatically diagnosed with HPD.
Many symptoms representing HPD in the DSM are exaggerations of traditional feminine behaviours. In a peer and self-review study, it showed that femininity was correlated with histrionic, dependent and narcissistic personality disorders. Although two thirds of HPD diagnoses are female, there have been a few exceptions. Whether or not the rate will be significantly higher than the rate of women within a particular clinical setting depends upon many factors that are mostly independent of the differential sex prevalence for HPD. Those with HPD are more likely to look for multiple people for attention, which leads to marital problems due to jealousy and lack of trust from the other party. This makes them more likely to become divorced or separated once married. With few studies done to find direct causations between HPD and culture, cultural and social aspects play a role in inhibiting and exhibiting HPD behaviours.
Histrionic personality disorder stems from Etruscan histrio which means “an actor”. Hysteria can be described as an exaggerated or uncontrollable emotion that people, especially in groups, experience. Beliefs about hysteria have varied throughout time. It wasn’t until Sigmund Freud who studied histrionic personality disorder in a psychological manner. “The roots of histrionic personality can be traced to cases of hysterical neurosis described by Freud.” He developed the psychoanalytic theory in the late 19th century and the results from his development led to split concepts of hysteria. One concept labelled as hysterical neurosis (also known as conversion disorder) and the other concept labelled as hysterical character (currently known as histrionic personality disorder). These two concepts must not be confused with each other, as they are two separate and different ideas.
Histrionic personality disorder is also known as hysterical personality. Hysterical personality has evolved in the past 400 years and it first appeared in the DSM II (Diagnostic and Statistical Manual of Mental Disorders, 2nd edition) under the name hysterical personality disorder. The name we know today as histrionic personality disorder is due to the name change in DSM III, third edition. Renaming hysterical personality to histrionic personality disorder is believed to be because of possible negative connotations to the roots of hysteria, such as intense sexual expressions, demon possessions, etc.
Histrionic personality disorder has gone through many changes. From hysteria, to hysterical character, to hysterical personality disorder, to what it is listed as in the most current DSM, DSM-5.[clarification needed] “Hysteria is one of the oldest documented medical disorders.” Hysteria dates back to both ancient Greek and Egyptian writings. Most of the writings related hysteria and women together, similar to today where the epidemiology of histrionic personality disorder is generally more prevalent in women and also frequently diagnosed in women.
First description of the mental disorder, hysteria, dates back to 1900 BC in Ancient Egypt. Biological issues, such as the uterus movement in the female body, were seen as the cause of hysteria.
Traditional symptoms and descriptions of hysteria can be found in the Ebers Papyrus, the oldest medical document.
Similar to ancient Egyptians, the ancient Greeks saw hysteria being related to the uterus.
Hippocrates (5th century BC) is the first to use the term hysteria.
Hippocrates believed hysteria was a disease that lies in the movement of uterus (from the Greek ὑστέρα hystera “uterus”).
Hippocrates’s theory was that since a woman’s body is cold and wet compared to a man’s body which is warm and dry, the uterus is prone to illness, especially if deprived from sex.
He saw sex as the cleansing of the body so that being overemotional was due to sex deprivation.
According to History Channel’s Ancients Behaving Badly, Cleopatra and Nero had histrionic personality disorder.
A group of three texts from the 12th century, discusses women’s diseases and disorders as understood during this time period, including hysteria.
Trota of Salerno, a female medical practitioner from 12th-century Italy, is an authoritative figure behind one of the texts of the Trotula.
Authoritative in that it is her treatments and theories that are presented in the text.
Some people believe Trota’s teachings resonated with those of Hippocrates.
The uterus was still the explanation of hysteria, the concept of women being inferior to men was still present, and hysteria was still the symbol for femininity.
Thomas Willis (17th century) introduces a new concept of hysteria.
Thomas Willis believed that the causes of hysteria was not linked to the uterus of the female, but to the brain and nervous system.
Hysteria was consequence of social conflicts during the Salem witch trials.
Witchcraft and sorcery was later considered absurd during the Age of Enlightenment in the late 17th century and 18th century.
Hysteria starts to form in a more scientific way, especially neurologically.
New ideas formed during this time and one of them was that if hysteria is connected to the brain, men could possess it too, not just women.
Franz Mesmer (18th century) treated patients suffering from hysteria with his method called mesmerism, or animal magnetism.
Jean-Martin Charcot (19th century) studied effects of hypnosis in hysteria.
Charcot states that hysteria is a neurological disorder and that it is actually very common in men.
Sigmund Freud’s work with Josef Breuer, Studies on Hysteria, contributes to a psychoanalytic theory of hysteria.
Freud believed that hysteria was caused by a lack of libidinal evolution.
The prevalence of histrionic personality disorder in women is apparent and urges a re-evaluation of cultural notions of normal emotional behaviour. The diagnostic approach classifies histrionic personality disorder behaviour as “excessive”, considering it in reference to a social understanding of normal emotionality.
Neurosis is a class of functional mental disorders involving chronic distress, but neither delusions nor hallucinations. The term is no longer used by the professional psychiatric community in the United States, having been eliminated from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980 with the publication of DSM III. However, it is still used in the ICD-10 Chapter V F40-48.
Neurosis should not be mistaken for psychosis, which refers to a loss of touch with reality. Nor should it be mistaken for neuroticism, a fundamental personality trait proposed in the Big Five personality traits theory.
The term is derived from the Greek word neuron (νεῦρον, ‘nerve’) and the suffix -osis (-ωσις, ‘diseased’ or ‘abnormal condition’).
The term neurosis was coined by Scottish doctor William Cullen in 1769 to refer to “disorders of sense and motion” caused by a “general affection of the nervous system.” Cullen used the term to describe various nervous disorders and symptoms that could not be explained physiologically. Physical features, however, were almost inevitably present, and physical diagnostic tests, such as exaggerated knee-jerks, loss of the gag reflex and dermatographia, were used into the 20th century. The meaning of the term was redefined by Carl Jung and Sigmund Freud over the early and middle 20th century, and has continued to be used in psychology and philosophy.
The DSM eliminated the neurosis category in 1980, because of a decision by its editors to provide descriptions of behaviour rather than descriptions of hidden psychological mechanisms. This change has been controversial. Likewise, according to the American Heritage Medical Dictionary, neurosis is “no longer used in psychiatric diagnosis.”
Symptoms and Causes
Neurosis may be defined simply as a “poor ability to adapt to one’s environment, an inability to change one’s life patterns, and the inability to develop a richer, more complex, more satisfying personality.” There are many different neuroses, including:
According to C. George Boeree, professor emeritus at Shippensburg University, the symptoms of neurosis may involve:
… anxiety, sadness or depression, anger, irritability, mental confusion, low sense of self-worth, etc., behavioral symptoms such as phobic avoidance, vigilance, impulsive and compulsive acts, lethargy, etc., cognitive problems such as unpleasant or disturbing thoughts, repetition of thoughts and obsession, habitual fantasizing, negativity and cynicism, etc. Interpersonally, neurosis involves dependency, aggressiveness, perfectionism, schizoid isolation, socio-culturally inappropriate behaviors, etc.
Carl Jung found his approach particularly effective for patients who are well adjusted by social standards but are troubled by existential questions. Jung claims to have “frequently seen people become neurotic when they content themselves with inadequate or wrong answers to the questions of life”. Accordingly, the majority of his patients “consisted not of believers but of those who had lost their faith”. Contemporary man, according to Jung,
…is blind to the fact that, with all his rationality and efficiency, he is possessed by ‘powers’ that are beyond his control. His gods and demons have not disappeared at all; they have merely got new names. They keep him on the run with restlessness, vague apprehensions, psychological complications, an insatiable need for pills, alcohol, tobacco, food — and, above all, a large array of neuroses.
Jung found that the unconscious finds expression primarily through an individual’s inferior psychological function, whether it is thinking, feeling, sensation, or intuition. The characteristic effects of a neurosis on the dominant and inferior functions are discussed in his Psychological Types. Jung also found collective neuroses in politics: “Our world is, so to speak, dissociated like a neurotic.”
According to psychoanalytic theory, neuroses may be rooted in ego defence mechanisms, though the two concepts are not synonymous. Defence mechanisms are a normal way of developing and maintaining a consistent sense of self (i.e. an ego). However, only those thoughts and behaviours that produce difficulties in one’s life should be called neuroses.
A neurotic person experiences emotional distress and unconscious conflict, which are manifested in various physical or mental illnesses; the definitive symptom being anxiety. Neurotic tendencies are common and may manifest themselves as acute or chronic anxiety, depression, an obsessive compulsive disorder, a phobia, or a personality disorder.
In her final book, Neurosis and Human Growth, Karen Horney lays out a complete theory of the origin and dynamics of neurosis. In her theory, neurosis is a distorted way of looking at the world and at oneself, which is determined by compulsive needs rather than by a genuine interest in the world as it is. Horney proposes that neurosis is transmitted to a child from his or her early environment and that there are many ways in which this can occur:
When summarized, they all boil down to the fact that the people in the environment are too wrapped up in their own neuroses to be able to love the child, or even to conceive of him as the particular individual he is; their attitudes toward him are determined by their own neurotic needs and responses.
The child’s initial reality is then distorted by his or her parents’ needs and pretences. Growing up with neurotic caretakers, the child quickly becomes insecure and develops basic anxiety. To deal with this anxiety, the child’s imagination creates an idealised self-image:
Each person builds up his personal idealized image from the materials of his own special experiences, his earlier fantasies, his particular needs, and also his given faculties. If it were not for the personal character of the image, he would not attain a feeling of identity and unity. He idealizes, to begin with, his particular “solution” of his basic conflict: compliance becomes goodness, love, saintliness; aggressiveness becomes strength, leadership, heroism, omnipotence; aloofness becomes wisdom, self-sufficiency, independence. What—according to his particular solution—appear as shortcomings or flaws are always dimmed out or retouched.
Once he identifies himself with his idealised image, a number of effects follow. He will make claims on others and on life based on the prestige he feels entitled to because of his idealised self-image. He will impose a rigorous set of standards upon himself in order to try to measure up to that image. He will cultivate pride, and with that will come the vulnerabilities associated with pride that lacks any foundation. Finally, he will despise himself for all his limitations. Vicious circles will operate to strengthen all of these effects.
Eventually, as he grows to adulthood, a particular “solution” to all the inner conflicts and vulnerabilities will solidify. He will be either:
Expansive, displaying symptoms of narcissism, perfectionism, or vindictiveness;
Self-effacing and compulsively compliant, displaying symptoms of neediness or codependence; or
Resigned, displaying schizoid tendencies.
In Horney’s view, mild anxiety disorders and full-blown personality disorders all fall under her basic scheme of neurosis as variations in the degree of severity and in the individual dynamics. The opposite of neurosis is a condition Horney calls self-realisation, a state of being in which the person responds to the world with the full depth of his or her spontaneous feelings, rather than with anxiety-driven compulsion. Thus the person grows to actualize his or her inborn potentialities. Horney compares this process to an acorn that grows and becomes a tree: the acorn has had the potential for a tree inside it all along.
Paranoid personality disorder (PPD) is a mental illness characterised by paranoid delusions, and a pervasive, long-standing suspiciousness and generalised mistrust of others.
People with this personality disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers. They think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.
They tend to be guarded and suspicious and have quite constricted emotional lives. Their reduced capacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience. People with PPD may have a tendency to bear grudges, suspiciousness, tendency to interpret others’ actions as hostile, persistent tendency to self-reference, or a tenacious sense of personal right. Patients with this disorder can also have significant comorbidity with other personality disorders (such as schizotypal, schizoid, narcissistic, avoidant and borderline).
PPD occurs in about 0.5-2.5% of the general population. It is seen in 2-10% of psychiatric outpatients. It is more common in males.
Paranoid personality disorder is listed in DSM-V and was included in all previous versions of the DSM. One of the earliest descriptions of the paranoid personality comes from the French psychiatrist Valentin Magnan who described a “fragile personality” that showed idiosyncratic thinking, hypochondriasis, undue sensitivity, referential thinking and suspiciousness.
Closely related to this description is Emil Kraepelin’s description from 1905 of a pseudo-querulous personality who is “always on the alert to find grievance, but without delusions”, vain, self-absorbed, sensitive, irritable, litigious, obstinate, and living at strife with the world. In 1921, he renamed the condition paranoid personality and described these people as distrustful, feeling unjustly treated and feeling subjected to hostility, interference and oppression. He also observed a contradiction in these personalities: on the one hand, they stubbornly hold on to their unusual ideas, on the other hand, they often accept every piece of gossip as the truth. Kraepelin also noted that paranoid personalities were often present in people who later developed paranoid psychosis. Subsequent writers also considered traits like suspiciousness and hostility to predispose people to developing delusional illnesses, particularly “late paraphrenias” of old age.
Following Kraepelin, Eugen Bleuler described “contentious psychopathy” or “paranoid constitution” as displaying the characteristic triad of suspiciousness, grandiosity and feelings of persecution. He also emphasized that these people’s false assumptions do not attain the form of real delusion.
Ernst Kretschmer emphasized the sensitive inner core of the paranoia-prone personality: they feel shy and inadequate but at the same time they have an attitude of entitlement. They attribute their failures to the machinations of others but secretly to their own inadequacy. They experience constant tension between feelings of self-importance and experiencing the environment as unappreciative and humiliating.
Karl Jaspers, a German phenomenologist, described “self-insecure” personalities who resemble the paranoid personality. According to Jaspers, such people experience inner humiliation, brought about by outside experiences and their interpretations of them. They have an urge to get external confirmation to their self-deprecation and that makes them see insults in the behaviour of other people. They suffer from every slight because they seek the real reason for them in themselves. This kind of insecurity leads to overcompensation: compulsive formality, strict social observances and exaggerated displays of assurance.
In 1950, Kurt Schneider described the “fanatic psychopaths” and divided them into two categories: the combative type that is very insistent about his false notions and actively quarrelsome, and the eccentric type that is passive, secretive, vulnerable to esoteric sects but nonetheless suspicious about others.
The descriptions of Leonhard and Sheperd from the sixties describe paranoid people as overvaluing their abilities and attributing their failure to the ill-will of others; they also mention that their interpersonal relations are disturbed and they are in constant conflict with others.
In 1975, Polatin described the paranoid personality as rigid, suspicious, watchful, self-centred and selfish, inwardly hypersensitive but emotionally undemonstrative. However, when there is a difference of opinion, the underlying mistrust, authoritarianism and rage burst through.
In the 1980s, paranoid personality disorder received little attention, and when it did receive it, the focus was on its potential relationship to paranoid schizophrenia. The most significant contribution of this decade comes from Theodore Millon who divided the features of paranoid personality disorder to four categories:
Behavioural characteristics of vigilance, abrasive irritability and counterattack.
Complaints indicating oversensitivity, social isolation and mistrust.
The dynamics of denying personal insecurities, attributing these to others and self-inflation through grandiose fantasies.
Coping style of detesting dependence and hostile distancing of oneself from others.
A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. A large long-term Norwegian twin study found paranoid personality disorder to be modestly heritable and to share a portion of its genetic and environmental risk factors with the other cluster A personality disorders, schizoid and schizotypal.
Psychosocial theories implicate projection of negative internal feelings and parental modelling. Cognitive theorists believe the disorder to be a result of an underlying belief that other people are unfriendly in combination with a lack of self-awareness.
The World Health Organisation’s ICD-10 lists paranoid personality disorder under (F60.0). It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria. It is also pointed out that for different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and other obligations.
PPD is characterised by at least three of the following symptoms:
Excessive sensitivity to setbacks and rebuffs;
Tendency to bear grudges persistently (i.e. refusal to forgive insults and injuries or slights);
Suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous;
A combative and tenacious sense of self-righteousness out of keeping with the actual situation;
Recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner;
Tendency to experience excessive self-aggrandising, manifest in a persistent self-referential attitude;
Preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to the patient and in the world at large.
Includes: expansive paranoid, fanatic, querulant and sensitive paranoid personality disorder.
Excludes: delusional disorder and schizophrenia.
The American Psychiatric Association’s DSM-5 has similar criteria for paranoid personality disorder. They require in general the presence of lasting distrust and suspicion of others, interpreting their motives as malevolent, from an early adult age, occurring in a range of situations. Four of seven specific issues must be present, which include different types of suspicions or doubt (such as of being exploited, or that remarks have a subtle threatening meaning), in some cases regarding others in general or specifically friends or partners, and in some cases referring to a response of holding grudges or reacting angrily.
PPD is characterised by a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts. To qualify for a diagnosis, the patient must meet at least four out of the following criteria:
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them.
Reads hidden demeaning or threatening meanings into benign remarks or events.
Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
Perceives attacks on their character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
The DSM-5 lists paranoid personality disorder essentially unchanged from the DSM-IV-TR version and lists associated features that describe it in a more quotidian way. These features include suspiciousness, intimacy avoidance, hostility and unusual beliefs/experiences.
Various researchers and clinicians may propose varieties and subsets or dimensions of personality related to the official diagnoses. Psychologist Theodore Millon has proposed five subtypes of paranoid personality (table below).
Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers.
Malignant paranoid (including sadistic features)
Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory delusions.
Paranoid personality disorder can involve, in response to stress, very brief psychotic episodes (lasting minutes to hours). The paranoid may also be at greater than average risk of experiencing major depressive disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder or alcohol and substance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as:
Because of reduced levels of trust, there can be challenges in treating PPD. However, psychotherapy, antidepressants, antipsychotics and anti-anxiety medications can play a role when a person is receptive to intervention.
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